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NA VMED P-5088 




Vol. 46 



Friday, 19 November 1965 



No. 10 




CONTENTS 



MEDICAL ARTICLES 



Surgeon General Attends Ceremony 1 

DENTAL SECTION (Cont'd) 



Terminal Mechanisms in Human Injury 

Skin Hemangiomas Found to Regress Without Treat- 
ment 

Cushing's Syndrome Due to Adrenocortical Tumor 

Physical Fitness in the Ready Reserve 

FROM THE NOTE BOOK 

Implantable Electronic Pacemakers 

Studies on Murine Leukemia 

Recovering the Use of Paralyzed Limbs 

Accuracy of Roentgenologic Examination in Detect- 
ing Carcinoma of the Colon 

Testing for Diabetes 

Naval Medical Residencies to Start Earlier 

DENTAL SECTION 

Comparison of Various Stains for Human Parotid 



13 

14 
14 
15 

15 
15 
16 



Saliva Proteins Separated by Acrylamide Gel Elec- 
trophoresis : 16 

Osseous Repair of the Post-Extraction Alveolus in 

Man 17 

Dental Pulp Hemogram 17 

Correction and Additional Explanation 18 

Personnel and Professional Notes 18 

OCCUPATIONAL MEDICINE SECTION 

The Worth of Occupational Health Programs — A New 
Evaluation of Periodic Physical Examinations 21 

EDITORIAL DESK 



Availability of Psychiatric Residencies in Naval 

Hospitals 27 

SecNavNote 1650 28 

Director, NNC Visits Naval Schools Command, New- 
port, R.I. 28 

Navy Meritorious Civilian Service Award 28 

A Moment of Happiness 29 



United States Navy 
MEDICAL NEWS LETTER 



Vol. 46 



Friday, 19 November 1965 



No. 10 



Rear Admiral Robert B. Brown MC USN 
Surgeon General 

Rear Admiral R. O. Canada MC USN 
Deputy Surgeon General 

Captain F. R. Petiprin MSC USN, Editor (Acting) 

William A. Kline, Managing Editor 

Contributing Editors 

Aviation Medicine Captain Frank H. Austin MC USN 

Dental Section Captain C. A. Ostrom DC USN 

Occupational Medicine CDR N. E. Rosenwinkel MC USN 

Preventive Medicine Captain J. W. Millar MC USN 

Radiation Medicine Captain J. H. Schulte MC USN 

Reserve Section Captain C. Cummings MC USNR 

Submarine Medicine Captain J. H. Schulte MC USN 



Policy 
The U.S. Navy Medical News Letter is basically an 
official Medical Department publication inviting the 
attention of officers of the Medical Department of the 
Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to 
medicine, dentistry, and allied sciences. The amount 
of information used is only that necessary to inform 
adequately officers of the Medical Department of the 
existence and source of such information. The items 
used are neither intended to be, nor are they, sus- 



ceptible to use by any officer as a substitute for any 
item or article, in its original form. All readers of the 
News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Change of Address 
Please forward changes of address for the News Letter 
to Editor: Bureau of Medicine and Surgery, Navy De- 
partment, Washington, D.C. 20390 (Code 18), giving 
full name, rank, corps, and old and new addresses. 



FRONT COVER: U.S. NAVAL HOSPITAL, GUAM, MARIANA ISLANDS. The history of the Navy's Med- 
ical Department on Guam began on 20 June 1898, when Passed Assistant Surgeon Ammen Farenholt, medical 
officer aboard the USS CHARLESTON, landed with the first American Forces on Guam during the Spanish- 
American War. It was not until the spring of 1899 that a naval occupational organization in the USS YOSE- 
MITE arrived at Guam. The medical officers of the vessel were Surgeon Philip Leach and Assistant Surgeon 
Alfred G. Grenwell. Thus the first Senior Medical Officer for the Guam area was Surgeon Leach. 

During this time Navy sick quarters were established, sanitary regulations were effected throughout Agana and 
outlying areas and, on 10 June 1901, the cornerstone was laid for the Maria Schroeder hospital in Agana. Staffed 
by Navy Medical Department personnel, the hospital cared for the indigenous population, military dependents 
and naval personnel. In 1905 the Susana Hospital for women and children was founded. Professional services 
again were furnished by the U.S. Navy Medical Department. In the same year islanders were vaccinated against 
smallpox. Another noteworthy achievement was the establishment in 1918 of a school for the instructions of 
midwives who were licensed when eligible. From 1905 to 1918 there had been 50 cases of tetanus neonatorum 
(umbilical cord infection), all of whom died. From 1918 on there were no reports of "cord tetanus." An ele- 
mentary course in hygiene was instituted in public schools; and a Tuberculosis Hospital was established in 1916 
at Agana Heights, near the location of the present hospital. 

During the period from December 1941 until July 1944 the island of Guam was occupied by forces of the 
Japanese Government. Following our re-capture of Guam, Naval medical facilities were established in July 1944 
as the U.S. Fleet Hospital, No. 103, later redesignated as U.S. Naval Hospital, Guam in January 1946. In March 
1946, the U.S. Naval Medical Center, Guam was commissioned under a Medical Officer in Command and was 
composed of the following activities: U.S. Naval Hospital; Guam Memorial Hospital; School of Medical Assist- 
ants; and School of Dental Assistants. In October 1949, the 22nd Army General Hospital was disestablished and 
the Navy assumed responsibility for care of all Armed Forces personnel entitled to hospitalization. 

The issuance of this publication approved by the Secretary of the Navy on 4 May 1964. 



U.S. NAVY MEDICAL NEWS LETTER 




Rear Admiral Robert B. Brown, Surgeon General of the Navy, unveils the plaque 
designating Building No. 2 of the Bureau of Medicine and Surgery as an historical 
landmark. Mr. T. Sutton Jett, (left) Regional Director of the National Park Service, 
made the presentation. The main address was delivered by Captain Joseph M. 
McDowell (center), Superintendent of the U. S. Naval Observatory. 



TERMINAL MECHANISMS IN HUMAN INJURY 

Francis D. Moore MD, Boston, Mass.* Amer J Surg 110(3): 317—323, 

September 1965. 



It is a privilege to be asked to discuss this topic in 
a symposium on circulatory failure because it is only 
by a critical examination of events in man that one 
can discern important directions for new work and 
significant interpretation of laboratory data from 
other species. It is likewise appropriate to begin with 
the examination of an individual case. This is always 

* From the Departments of Surgery, Harvard Medical School and 
Peter Bent Brigham Hospital, Boston, Mass. This work was carried 
out with the support of the U.S. Army Medical Research & Develop- 
ment Command. 



a refreshing discipline in discussions of a subject that 
tends to lapse into generalities. 

Case Report 

This is the case of a twenty-eight year old man 
(L. P. #5-58-69) who fell from a third-story win- 
dow onto hard pavement. On admission to the hos- 
pital he displayed an obvious fracture of the pelvis, 
some instability of the ribcage, but was conscious 
and showed normal cranial and spinal reflexes. The 



U.S. NAVY MEDICAL NEWS LETTER 



blood pressure, initially 90/50 mm Hg, fell rapidly 
to a systolic value of 50 mm Hg. The peripheral 
appearances were those of early traumatic hypoten- 
sion with diifuse reduction in tissue perfusion. 

Triple catheterization was immediately carried 
out. A venous catheter was placed so that low molec- 
ular weight dextran might be administered along 
with blood, mannitol, and fluids. A right brachial 
artery cutdown was performed for continuous moni- 
toring of blood pressure, pulse contour, and arterial 
blood gas analysis; a urethral catheter was placed to 
establish the presence of urethral continuity and pro- 
vide data on short-term urinary outputs. Concentrat- 
ed human albumin was started as the first infusion, 
and within a few minutes type-specific whole blood 
transfusion was commenced, which soon returned 
the systolic blood pressure to levels of 90 to 120 
mm Hg. Because of the instability of the ribcage, 
and some apprehension as to the ventilatory status, 
an endotracheal tube was passed for assisted ventila- 
tion. This could be maintained readily with full co- 
operation of the patient, maintenance of conscious- 
ness, and minimal medication. 

Blood pressure was very difficult to maintain at a 
satisfactory level during the first twenty hours be- 
cause of ongoing retroperitoneal hemorrhage. 
During the first night he required a total of 11.5 L 
of blood (23 units), and for the next twenty-four 
hours an additional 7.5 L (15 units) was adminis- 
tered. At no time did any external bleeding occur. 
Because of apprehension as to thrombocytopenia 
even though most of his recorded platelet counts 
were in a normal range, some of the blood adminis- 
tered was given without filtration. Much of this 
blood was very fresh, less than one hour intervening 
between withdrawal from the donor and infusion to 
the patient. 

Because of continuing abdominal tenderness an 
exploratory laparotomy was carried out, demonstrat- 
ing no visceral rupture or open hypogastric artery 
but instead a massive pelvic and extraperitoneal hem- 
orrhage arising particularly from the posterior 
fracture of the blade of the ilium on the left. 

Although blood pressure was at normal levels 
much of the time, the patient was in a low-flow state 
intermittently with oliguria, tachycardia, and every 
evidence of maximal adrenocortical and adrenomed- 
ullary activity. This continued for approximately 
forty hours. 

The circulation finally stabilized after a total of 21 
L of blood had been infused. Because of continuing 
suspicion of a bleeding tendency he had been given 



calcium gluconate, epsilon aminocaproic acid, and 
fibrinogen; laboratory measurement failed to dis- 
close any bleeding tendency. Repeated monitoring of 
the plasma volume showed it to be in the normal or 
high normal range. Blood volume was likewise nor- 
mal or high. 

By the end of twenty-four hours it was evident 
that the patient was in acute renal insufficiency de- 
spite priming doses of mannitol and generous fluid 
therapy; no evidence of ureteral obstruction on 
either side was noted. There was no response in 
urinary volume to the increased rate of infusion. 

Initially, analysis of blood gases showed respira- 
tory function to be adequate, with a normal C0 2 
tension. In addition he showed a normal response of 
arterial oxygen tension, rising to 470 mm Hg in re- 
sponse to the inhalation of 100 per cent oxygen for 
a short test period. No physiologic shunt was as yet 
evident. 

By the following day (fourth day after injury) the 
patient's respiration became increasingly difficult, 
and some increase in inspiratory pressure was re- 
quired during his increasingly frequent periods on 
machine-driven assisted ventilation. The endotra- 
cheal tube was maintained in position with minimal 
additional anesthesia. Auscultatory signs at this time 
included diffuse rales and rhonchi although the lung 
fields were relatively clear by x-ray film. During as- 
sisted ventilation, every attempt was made to main- 
tain the patient on the lowest possible oxygen ten- 
sion compatible with satisfactory oxygenation, with 
maximal humidity in the inspired air, and with sev- 
eral deep breaths or sighing respirations every few 
minutes. 

Urinary output was never resumed. Petechiae 
over the chest wall suggested fat embolization, but 
fat was not demonstrable in urine or sputum. Blood 
pressure continued to fluctuate; norepinephrine and 
cortisone were added to the infusion. Repeated 
blood cultures gave negative results. No gastrointes- 
tinal bleeding was noted. Abdominal signs continued 
to show the tenseness associated with a large retro- 
peritoneal hemorrhage. Peristalsis was resumed. 
There were increasing evidences of peripheral anox- 
ia; pH began to fall and terminally reached a value 
of 7.12 despite an essentially normal carbon dioxide 
tension, indicating a mounting base deficit and the 
accumulation of a large amount of metabolic acid. 
The terminal event was cessation of the heart beat 
while blood pressure was precariously maintained 
close to normal with vasopressors. External manual 
systole was unavailing. He died on the twelfth day 
after injury. 



U.S. NAVY MEDICAL NEWS LETTER 



Postmortem examination showed multiple frac- 
tures of the pelvis with a separation of the symphysis 
pubis. There was massive retroperitoneal, scrotal, 
and intra-abdominal hemorrhage estimated by the 
pathologist to total 3,500 ml. There was acute tubu- 
lar necrosis bilaterally symmetrical. There was no 
ureteral obstruction. Neither kidney was ruptured. 
The lungs showed congestion with increased weight 
due to the accumulation of interstitial fluid. There 
was acute aspiration tracheitis and bronchitis, and 
several areas of beginning pneumonitis. Small fat 
emboli were present; pneumothorax resulted from 
manual systole. A disorder of the liver or portal cir- 
culation was not evident; slough or hemorrhage into 
or around the gut mucous membrane at any point 
was not noted. There were no areas of focal infec- 
tion although positive cultures for Klebsiella aero- 
bacter could be obtained from the tracheobronchial 
tree. There was a small area of cerebral infarction in 
the right frontal lobe compatible with a contrecoup 
injury or possibly a small cerebral embolus. 

Of What Did He Die? 

This detailed case history has several points of in- 
terest. It is the case of an injury to an otherwise 
healthy young man; he suffered at one point from 
unrelieved hypotension, and throughout much of the 
course from a circulatory disorder in which blood 
pressure was extremely difficult to maintain even 
though continued bleeding was not always evident; 
there was no septic process either focal or general 
although terminal colonization of the tracheobron- 
chial tree occurred. However, the principal reason 
for discussing this case at all is to dwell for a mo- 
ment on the matter of prime causes, the meaning of 
such causes for research, and the semantics of severe 
injury. 

In 1910 this patient would have been referred to 
as having died of a fractured pelvis. In 1920 blood 
transfusions having become available on a small 
scale, he would have been referred to as having died 
of hemorrhage even though the previous five years 
had included Dr. Cannon's beginning trend towards 
the use of the term "shock" in civilian injuries as so 
widely applied during World War V. By 1925 this 
death would quite clearly have been stated to be due 
to shock. At any time prior to this the patient almost 
surely would have died in his first ninety-six hours, 
as liberal blood replacement at this magnitude plus 
assisted ventilation were not generally available — 
methods of great value in treatment, yet carrying 
their own special hazards. 

By 1945 the use of the dog preparation for the 



study of shock had come into wide use because of 
stimulus by the office of Scientific Research and De- 
velopment during the war, and again it was noted 
(as it had been thirty years previously by Cannon in 
experiments with cats) that unrelieved prolonged 
hypotension produced a situation that was difficult 
to reverse. The term "irreversible shock" therefore 
came into vogue. By careful laboratory study this 
picture could be defined long before death and in- 
cluded massive hemorrhage from the gut, portal hy- 
pertension after retransfusion, a tense swollen liver, 
failure to regain consciousness over a period of 
many hours, and frequently the finding at autopsy of 
multiple small myocardial necroses. This patient had 
shock and he died, so surely by any definition he 
was "irreversible"! Furthermore one could assume 
that his gastrointestinal tract was well populated 
with colon bacilli, and he seemed to have a require- 
ment of blood far in excess of any measured losses. 
So, during the period 1945 to 1950, this patient 
would have been referred to as having died of irre- 
versible shock and that would be considered a good 
and sufficient cause for anybody to die 2 . Many 
workers with the wounded in the Korean War began 
to develop a suspicion of this terminology when it 
became evident that many wounded men who had 
been in refractory hypotension for many hours were 
indeed quite reversible if proper diagnosis and treat- 
ment were instituted for focal lesions, and it was dis- 
covered, both in World War II and Korea, that inev- 
itable colonization with micro-organisms was not a 
part of human injury, as it was in the dog. 

With description of the crush syndrome by By- 
waters in 1943 3 and the increasing recognition of 
renal failure, closely followed by the development of 
the artificial kidney, there was increasing awareness 
of the fact that acute tubular necrosis could be ex- 
pected in patients who made no urine after severe 
injury and who had mounting azotemia, elevated po- 
tassium (here 6.6 mEq/L), and peaked T-waves in 
the electrocardiogram, and for this reason there 
would be good cause to state that this patient died of 
post-traumatic renal insufficiency 4 . 

Intermittently since the mid-1930's there has 
been interest in enzymatic alterations in the low flow 
state; there is general agreement that prolonged defi- 
ciency of flow to cellular organs produces alterations 
in their enzymatic activity measurable either in the 
form of abnormal end products such as lactic acid 5 ' , 
in the build-up of abnormal enzymes in the blood 
such as lactic dehydrogenase and transaminase, or in 
abnormal enzymatic activities in specific tissues such 
as kallikrein of pancreas, and in oxidative enzymes 



U.S. NAVY MEDICAL NEWS LETTER 



in the mucous membrane of the gut 7 . These cellular 
changes are the result of prolonged anaerobiosis in 
cellular tissues. The accumulation of these abnormal 
metabolic products makes resuscitation difficult, so 
that one might well state that this patient died of 
prolonged deficiency of tissue perfusion. 

The close monitoring of such a patient permits a 
number of measurements to be made precisely at the 
time of death, and by continuous electrocardiogra- 
phic tracing it becomes evident that most patients at 
the time of death have cessation of the heart beat 
prior to cessation of that other vital function without 
which life is absent, namely, the brain. In looking at 
the terminal electrocardiogram in such a patient as 
this, one might be tempted to state that he died of 
cardiac arrest. Whether the arrest is initially diastolic 
in character or later becomes ventricular fibrillation 
is of major importance in resuscitation of more favor- 
able cases but of relatively little interest as to mech- 
anism. In patients such as this, so-called "cardiac 
arrest" has occurred because the biochemical envi- 
ronment of the heart will not permit normal contin- 
ued neuromuscular irritability and reactivity. Low 
coronary perfusion rates with associated changes in 
the ST segment later compounded by severe anoxia 
and lactic acidosis produce this cessation of the 
heart beat; attempts at resuscitation in such cases 
are futile for the reason they were here, namely, that 
the altered biochemical environment cannot be nor- 
malized by the mere act of restoring the heart beat 
or pumping the heart as^a substitute for; normal sys- 
tole. 

To the pathologist schooled' in conventional post- 
mortem terminology, there is little doubt that this 
patient died of some sort of pneumonic process prob- 
ably aspiration, bronchopneumonia, fat embolism, 
and pneumothorax. Unquestionable evidence of 
aspiration was present, there was a mixed pulmo- 
nary lesion with some infiltrate, the lungs were heavy, 
and the transient attempts at cardiac resuscitation 
had produced a pneumothorax. Organisms had been 
recovered from the tracheobronchial tree below the 
vocal cords. 

Finally, it would be difficult to exclude the head 
injury as contributing to the fatality. The precise 
cause was not wholly clear, and there were no early 
changes in spinal or cerebral nerve reflexes; the pa- 
tient had been conscious and very well oriented 
throughout his first several days. Despite these fac- 
tors the postmortem findings would include cerebral 
injury with infarction as a major cause of death. 

Only to the most ardent devotee of the canine 
preparation would it be justified to refer to this pa- 



tient as having died of endotoxin shock although 
surely such would be invoked by those who might also 
employ the term "irreversible shock." It is note- 
worthy that he had no hepatic engorgement and no 
evidence of gastrointestinal hemorrhage despite the 
extensive bleeding in other sites. 

Lethal Outcome 

Such cases as this are commonplace and in a 
sense typical; nonetheless it is essential to look at 
the terminal events in large groups of patients to see 
if any significant patterns emerge; such efforts have 
occupied the attention of several laboratories In this 
country during the past deeade. Our initial effort 
was devoted to the whole population of patients in 
our hospital suffering from any sort of hemorrhagic, 
traumatic hypotension, or severe injury. In the 
course of about eighteen months we readily corrobo- 
rated the obvious fact that the vast majority of these 
patients are very easily resuscitated using conven- 
tional methods which quickly come to hand 8 . Blood 
transfusion and proper ventilation are surely the 
most important. One cannot but look with skepti- 
cism at reports of large series of unselected patients 
in which high survival values are claimed for some 
agents such as low molecular weight dextran, vasodi- 
lators, mannitol, or particular sorts of ventilatory 
apparatus; any large and unselected group of pa- 
tients with traumatic hypotension can show a very 
high survival rate with or without the use of any 
single drug or machine, providing blood is available 
and careful clinical diagnosis is maintained. 

However, in addition to that large group of easily 
rescued patients, there was a small hard core of very 
difficult problems similar to those encountered in the 
patient just described in some detail. It is this "hard 
core group" of patients with refractory hypotension 
with whom all workers today are concerned. These 
patients were referred to as suffering from "refrac- 
tory hypotension" as a feature of prolonged defi- 
ciency of blood flow, inadequate tissue perfusion, 
and widespread anaerobiosis. In our first report of 
patients suffering from refractory hypotension we 
found that the combination of bloodstream infection 
with severe pulmonary insufficiency was the most 
highly lethal; we rediscovered the obvious fact that 
restoration to normal of some of the biochemical pa- 
rameters of the blood (such as acidosis) would of- 
ten make possible the restoration of blood pressure 
and flow by transfusion". 

That initial series of studies has been followed by 
a current group of patients in whom measurements 



U.S. NAVY MEDICAL NEWS LETTER 



have been much more discriminating with respect to 
anaerobic metabolism, the products of that metabo- 
lism, in the blood, bacteriologic study of the blood, 
and local infection sites, blood volume, and an at- 
tempt to use more rigorous diagnostic methods and 
terminology in severe injury. Reviewing these cases 
currently under study, we find that the most com- 
mon causes of death after severe injury in man or 
after extensive surgical operations, particularly in 
persons with disease of heart, lungs, or kidney, are 
as follows: 

1, An oblkerative pneumonitis as, a complication 
of prolonged low blood flow with multiple blood 
transfusions; there is anoxia early, hypercarbia late, 
lactic acidosis with an elevated value for excess lac- 
tate, with terminal cessation of the heart beat prior 
to cessation of other functions. The pathologist finds 
a lung lesion that is a mixture of atelectasis, pulmo- 
nary edema, small pulmonary emboli, bronchopneu- 
monia, and all too frequently aspiration. Fat emboli 
are sometimes present. Physiologic measurement 
shows the development of an increasingly significant 
right to left shunt of blood that is passed through the 
pulmonary circuit without being oxygenated. The lo- 
cal toxic effects (in the lung) of high oxygen ten- 
sions in the inspired air cannot be denied as a pos- 
sible lethal mechanism in many cases; changes in 
pulmonary surfactant may be the intermediary mech- 
anism whereby high oxygen tensions alter the 
compliance and inflatability of the lung. If one seeks 
a single organ lesion in man that is not readily re- 
versed by treatment, this is it. The bacteriologic pic- 
ture is compounded by the use of many antibiotics; 
the tracheobronchial tree is colonized with orga- 
nisms at death, and it would be almost inconceivable 
to consider such a trachea as being sterilized by the 
use of any combination of antibiotics; in most such 
cases, however, this colonization does not seem to 
be of primary etiologic importance. 

2. In sharp contrast are those patients whose 
death is clearly due to overwhelming infection with a 
positive blood culture; blood volume must be sup- 
ported at values far above normal to support pres- 
sure and flow. Pulmonary changes may or may not 
be present with these patients; some sort of toxemia 
whether due to an endotoxin or an exotoxin cer- 
tainly appears to be important in the production of 
the hypotensive state. It is noteworthy that in our 
experience to date we have never seen this sequence 
of hypervolemic septic hypotension in the absence of 
a positive blood culture. The patient suffering from 
gram-negative bacteremia comes closest to an ap- 



proximation of the canine shock preparation with 
endotoxemia, although many differences are still ap- 
parent particularly in the portal circulation. 

3. Post-traumatic renal insufficiency is yet an- 
other cause. There is a small group in whom the 
unrelieved renal failure is a predominant and indubi- 
table cause of death; multiple dialyses, even as fre- 
quent as daily, may fail to resuscitate the patient if 
the rest of the injury is severe. It is noteworthy that 
in our experience with burns complicated by renal 
failure, we have never had a survival in a patient in 
whom renal failure was severe enough to require 
repeated dialyses and in whom the burn covered 
more than 30 per cent of the body surface. In pa- 
tients who die with post-traumatic renal insufficiency, 
any one of the two above-named features may also 
be present (obliterative pneumonitis or overwhelm- 
ing infection). On looking over patients and records, 
however, it is not difficult to discern those in whom 
renal failure was the most stubborn initial complex- 
ity without which survival might have been attained. 
Despite all efforts to minimize the problem, hyper- 
kalemia with acidosis is usually the terminal mech- 
anism in renal failure. 

4. Sudden massive exsanguinating hemorrhage 
from an ulcer in the upper gastrointestinal tract is 
occasionally a terminal event in these patients partic- 
ularly if given steroids, or who with transfusion 
have become thrombocytopenic. This is riot associat- 
ed with a diffuse slough of the mucous membrane of 
the gut, and it occurs in the absence of cortisone 
therapy although the latter is, of course, dangerous 
on this account. If prolonged deficiency of blood 
flow produces enzymatic changes in the gut associat- 
ed with the loss of viability of the mucous mem- 
brane, this might be the manifestation in man of 
such a tendency; the acid peptic diathesis, so much 
more prominent in man than in the dog, may serve 
to focalize this lesion in the upper rather than the 
lower part of the gut. 

5. Finally, there is a small group with direct 
trauma to a particular organ (particularly the heart, 
brain, and liver) in which a specific visceral rupture 
or disruption is incompatible with recovery. Head 
injury leads the list here. 

In all of the aforementioned, prolonged deficiency 
of blood flow is the cause of diffuse anaerobiosis 
which produces gradual loss of viability of many tis- 
sues; continuous electrocardiographic tracings at the 
time of death will show that diastolic arrest or ven- 
tricular fibrillation are the events which demonstrate 
death of the patient; a few minutes later the brain 



U.S. NAVY MEDICAL NEWS LETTER 



suffers permanent widespread damage due to anoxia, 
and the patient is said to be dead even though many 
other tissues remain viable as demonstrated by 
subsequent study in vitro or in vivo. All tissues have 
been dying for some hours; when heart and brain 
cease, the patient himself is said to be dead; the de- 
cay curve of the other tissues continues downward 
until after another sixty to ninety minutes under nor- 
mothermic or slow-cooling conditions all of the tis- 
sues have suffered irreparable damage. 

In such circumstances, with prolonged deficiency 
of flow to tissues, one finds extensive slowing of the 
passage of blood in small capillary and postcapillary 
venules, with stagnation. There is loss of fluid and 
increase in local erythrocyte concentrations under 
some experimental and clinical circumstances. These 
changes in the microcirculation are accentuated by 
the fact that blood has a non-Newtonian character 
by which is meant that at low rates of flow (that is, 
low energy inputs) the blood is much more highly 
viscous and difficult to move than it is at higher rates 
of flow. When cardiac output is low, the energy 
transmitted to the microcirculation is minimal, and 
this sluggishness of flow associated with aggregation 
of erythrocyte is noticeable. Anything that increases 
cardiac output and increases the transmission of pul- 
satile flow and energy into the microcirculation 
restores it towards normal. Ordinary blood trans- 
fusion in early hypotension, for example, is capable 
of restoring the microcirculation completely to 
normal by restoring cardiac output and bringing back 
to normal the energy input to the capillaries and 
postcapillary venules. It remains to be seen whether 
or not such agents as normal saline solution or low 
molecular weight colloids, which lower the concen- 
tration of proteins and erythrocytes in the blood, are 
of particular usefulness in helping to restore tissue 
perfusion to normal when stagnation in the micro- 
circulation has been of long duration. Whatever 
therapeutic improvements may result, the devotion 
of increased attention to the microcirculation has 
re-emphasized the physics and hemodynamics of 
prolonged deficiency of flow in cellular organs. 10 ' 11 

What Has Become of Shock 

Where, then, do these developments lead us with 
respect to "shock" as seen and conceived by Dr. 
Cannon in 1 91 5? We must conclude that medical 
science has moved beyond such simplified terminol- 
ogy. To lump this fascinating and challenging group 
of interwoven ailments, most of which are mutually 
self-sustaining, some of which are biochemical, some 
bacteriologic, and some organ-dominated, into one 



diagnosis such as "shock" is as meaningless as a ref- 
erence to all patients with brain tumors as suffering 
from elevated pressure of the cerebrospinal fluid. It 
is up to the scientists of this decade, given more 
effective methods than ever for maintaining life in 
patients and more rigorous scientific methods than 
formerly available, to discriminate among these var- 
ious initiating and sustaining factors in tissue anaer- 
obiosis. Only by a realistic view of this confusing 
and multifaceted picture in man will important new 
methods of therapy arise. 

Where do such considerations leave us as we look 
at the laboratory model, consisting of the arterial- 
bled dog with prolonged hypotension and death after 
subsequent retransfusion? This animal has become 
the subject of study in many laboratories as the Na- 
tional Institutes of Health and the Office of the Sur- 
geon General have succeeded the Office of Scientific 
Research and Development, making available large 
sums of money for surgical laboratories to investi- 
gate low flow states under controlled conditions. 
Although the experiments vary in detail, they all 
share the common property first noted by Dr. Can- 
non in the cat, namely, that an animal made hypo- 
tensive by bleeding shows a time parameter which is 
limiting as to survival; if flow and pressure are not 
restored prior to elapse of that time, the diffuse tis- 
sue anaerobiosis is sufficiently severe in producing 
cellular damage so that resuscitation cannot be at- 
tained. If dogs under such circumstances show some 
improvement in survival with hyperbaric oxygen, 
low molecular weight colloids, vasodilating drugs, 
preliminary treatment with antibiotics or the use of 
energy-rich phosphate compounds, it is only natural 
and appropriate that such should be tried in man. 
When evaluated in man, however, the appraisal of 
any such new therapy must be carried out with care- 
ful sequential longitudinal study of each case as a 
prospective research. 

Actually, the resolution of contrasts between ro- 
dents, dogs, monkeys, cats, and man is to be sought 
in a distinction between cellular changes and inte- 
grated whole-body responses. Vertebrates subjected 
to prolonged deficiency of blood flow show cellular 
changes, anaerobic metabolism, and enzymatic alter- 
ations which appear to be common to all species. 
Turning from cellular respiration and metabolism to 
a larger view of the whole animal, the differences 
become very marked; bacteriologic, postural, circu- 
latory, and specific organ arrangements show 
marked differences between the species. As regards 
the dog these are most important with respect to the 
fact that the animal is a pronograde carnivore de- 



U.S. NAVY MEDICAL NEWS LETTER 



void of many of the postural reflexes seen in man, 
diffusely colonized with micro-organisms which be- 
come active under anaerobic conditions, and partic- 
ularly prone to the development of portal hyperten- 
sion and bleeding from the gut as well as multiple 
small myocardial necroses when a period of pro- 
longed hypotension is 'followed by liberal transfu- 
sion. 

The particular vulnerability of man appears to be 
in the lungs rather than in this splanchnohepatic 
area. In man, attention must be devoted to the pul- 
monary effects of massive blood transfusion. In the 
patient cited, 21 L or approximately five times the 
normal blood volume was infused directly into the 
right side of the circulation over a period of about 
ninety-six hours. The lungs are the first capillary bed 
and the "filter" through which this infused blood is 
conducted; if rapidly infused, some of the blood 
transfusion strikes the lungs in virtually undiluted 
concentration. In the case considered, some of the 
blood was given without filtration to preserve plate- 
let activity. In any transfusion the possibility of mul- 
tiple small emboli cannot be ruled out. Whether fil- 
tered or not, one is infusing directly into the lungs 
(by the pulmonary artery, right heart, and great 
veins) a large volume that may contain microem- 
boli, platelets, or erythrocytes, and that certainly 
contain immunologically incompatible substances. It 
is of interest that one group currently working in 
London 1 - has brought forth evidence to show that 
the use of extremely fresh blood, so common today, 
carries viable leukocytes directly to the lung which 
may there initiate a graft versus host reaction mani- 
fested a few days later by an obliterative pneumon- 
itis with a large physiologic shunt. These lesions add 
a ventilatory anoxemia to the diffuse tissue anoxia 
already initiated by the deficiency of blood flow. 

Whatever the ultimate fate of this particular con- 
cept, I should like to conclude my brief presentation 
with a plea to look increasingly closely at phenom- 
ena seen in man and to pattern laboratory studies 
after the realities of surgical care today. It is impor- 
tant to see from what the patient is suffering and 
what injury we inflict with therapy. 

The ancient term "shock" with its connotation of 
a simple unified mechanism, should be abandoned 
and ordinary clinical terminology used to describe 
the events and terminal mechanisms seen after se- 
vere injury. 

REFERENCES 

J. Cannon, W. B. Traumatic Shock. New York, 1923, D. Appleton 
& Co. 

2. Fine, J. Septic shock. JAMA 188: 127, 1964. 

3. Bywaters, E. G. L. Ischemic muscle necrosis. JAMA 124: 1103, 

1944. 



4. Merrill, J. P., Thorn, G. W., Walter, C. W., Callahan, E. J., IV, 
and Smith, L. H., Jr. The use of an artificial kidney, J Clin 
Invest 29: 412, 1950. 

5. Lyons, J. H., Jr., Lee, C. J,, Aquino, C„ and Moore, F. D. 
Biochemical patterns in septic shock: the role of hypoxic acidosis. 
In Press. Proceedings of National Academy of Sciences National 
Research Council Workshop on Septic Shock (September 11-12, 
1964). 

6. Clowes, G. H. A., Jr., Sabga G., Konitaxis, A., Tomin, R., 
Hughes, M., and Simeone, F. A. Effects of acidosis on cardio- 
vascular function in surgical patients. Ann Surg 154: 524, 1961. 

7. Buonous, G., Hampson, L. G., and Gurd, F. N. Cellular nucleo- 
tides in hemorrhagic shock: relationship of intestinal metabolic 
changes to hemorrhagic enteritis and the barrier function of 
intestinal mucosa. Ann Surg 160: 650, 1964. 

». Smith, L. L., Hamlin, J. T., Ill, Walker, W. F., and Moore, 

F. D. Metabolic and edocrinoiogic changes in acute and chronic 

hypotension in man. Metabolism 8: 862, 1959. 
9. Smith, L. L. and -Moore, F. D. Refractory hypotension in man — 

is this irreversible shock? Clinical and biochemical observations. 

New England J Med 267: 733, 1962. 

10. Knisely, M. U. Methods for direct investigation of factors lead- 
ing to thrombosis. Conference on Blood Clotting and Allied 
Problems, Josiah Macy Jr. Foundation, 1951. 

1 1 . Gelin, L. E. Disturbance of the flow properties of blood and 
its counteraction in surgery. Acta ehir scandinav 122: 287, 1961. 

12. Melrose, D. G. et al. Postoperative hypoxia after extracorporeal 
circulation: A possible graft-against-host reaction (preliminary 
communication). Experientja 21: 47, 1965. 



SKIN HEMANGIOMAS FOUND TO RE- 
GRESS WITHOUT TREATMENT 

Pediatric Herald 6(7): 1, September— October 1965. 

New York. With no treatment other than reassur- 
ance of an anxious parent, most cutaneous heman- 
giomas in children will regress. 

This conclusion was reached by two U.S. Navy 
pediatricians who followed 330 hemangiomas for 
two to four years in a series of 204 infants and chil- 
dren. 

The investigators said that "most important in the 
conservative approach is the physician's attitude, his 
interest in the problem, and his relationship with the 
patients." 

They used photographs taken every few months 
to document regression and found that this "quickly 
allayed parental anxiety." 

The majority of hemangiomas are present at birth 
or appear during the first month, the physicians said, 
although a few may not be noted until the first few 
months. The usual course is rapid growth for the 
first six to nine months, a stationary period of sever- 
al months, and finally a gradual period of spontan- 
eous regression. 

They noted that one of the earliest signs of regres- 
sion is the appearance of white-grey streaks on the 
surface of the lesion. "Recurrent trauma, repeated 
irritation, and ulceration of these lesions appear to 
accelerate regression," they observed. 

The study found that hemangiomas regressed 
completely (or more than 50 percent) at this rate: 
30 percent at age three years; 60 percent at four; 
and 75 percent at seven. 

The physicians commented on the fact that spon- 
taneous involution in children was reported as early 



U.S. NAVY MEDICAL NEWS LETTER 



as 1888, and confirmed in later studies. "Yet consid- 
erable diversity of opinion still exists among physi- 
cians" regarding management of the common der- 
matologic condition. Despite the earlier studies, 
many papers have advocated such treatment as sur- 
gery, x-ray, dry ice, injections, and radon seed im- 
plants, the authors said. In patients treated else- 
where prior to entering their study, they said they 
noted "unfortunate complications of irradiation and 
injection therapy." 

"We hold," they concluded, that "conservative 



management with continued close observation (pos- 
sibly massage) during infancy will provide an excel- 
lent cosmetic result in later years." 

CAPT A. M. Margileth MC USN, chief of 
pediatric service at the U.S. Naval Hospital in 
Bethesda, Md. and CDR M. Museles MC USN, 
chief of pediatric service at the Naval Hospital in 
Portsmouth, Va., presented their findings in a scien- 
tific exhibit at the recent meeting of the American 
Medical Association. 



CUSHING'S SYNDROME DUE TO ADRENOCORTICAL TUMOR 

11 -Year Review of 15 Patients 

H. William Scott Jr. MD, John H. Foster MD, Grant Liddle MD, Eugene T. 

Davidson MD. From the Departments of Surgery and Medicine, Vanderbilt 

University School of Medicine, Nashville Tennessee. 

Annals of Surgery 162(3): 505-513, September 1965. 



During the past decade a number of developments 
have combined to increase the ease and accuracy 
with which Cushing's syndrome can be diagnosed 
and treated. In his classic description of the syn- 
drome in 1932, Cushing 2 emphasized the clinical 
features of central obesity, osteoporosis, amenor- 
rhea, hirsutism, striae, hypertension and weakness. 
At that time he attributed these changes to pituitary 
basophilism. Anderson and her coworkers 1 in 1938 
were among the first to present evidence that the 
probable common denominator in all cases of Cush- 
ing's syndrome was hyperactivity of the adrenal cor- 
tex. We may now define Cushing's syndrome as a 
group of clinical and metabolic disorders which re- 
sult from an excess of Cortisol (hydrocortisone). 

Apart from the medicinal use of hormones, an ex- 
cess of Cortisol results most commonly from bilateral 
adrenal cortical hyperplasia under the stimulatory 
effect of increased secretion of ACTH by the pitui- 
tary. The latter may or may not contain an aden- 
oma. In what is probably the next most common 
situation, Cushing's syndrome results from a nonen- 
docrine tumor which secretes ACTH or an ACTH- 
like polypeptide. 11 The next most common cause of 
the syndrome is adrenocortical tumor. This report 
summarizes our experience with Cushing's syndrome 
caused by adrenocortical tumor, with special em- 
phasis on precise diagnosis and surgical treatment. 

Clinical Material 
During the last 1 1 years at Vanderbilt University 



Hospital and the affiliated Veterans Administration 
Hospital, we have had the opportunity to see and 
treat surgically 15 patients with Cushing's syndrome 
due to adrenocortical tumor (Table 1). During the 
same period more than 50 patients with Cushing's 
disease due to over-production of ACTH by the pi- 
tuitary and bilateral adrenal hyperplasia have been 
studied and treated. Ages ranged from 9 months to 
63 years; there were three men and 12 women. 
Many patients presented only a few of the classical 
findings of the syndrome and even hypertension and 
obesity were occasionally absent. While the clinical 
picture alone is sometimes sufficiently clear to estab- 
lish the diagnosis of Cushing's syndrome, it is fre- 

Table 1 

Incidence of Classic Clinical Manifestations in 

1 5 Patients with Cushing's Syndrome Due to 

Adrenal Tumor 



Central obesity 


14/15 


Hypertension 


13/15 


Impaired glucose tolerance 


11/13 


Mental aberrations 


10/13 


Weakness 


8/13 


Hirsutism 


9/15 


Osteoporosis 


8/15 


Ecchymoses 


7/15 


Edema 


7/15 


Striae 


4/15 


Menstrual aberrations 


5/9 



U.S. NAVY MEDICAL NEWS LETTER 



quently necessary and always desirable to confirm 
the clinical impression by special studies of adreno- 
cortical function and adrenal-pituitary relationships. 
Such studies are of extreme importance in differen- 
tiating Cushing's syndrome due to adrenal hyperpla- 
sia, extra-endocrine tumor and adrenal tumor. In 
addition, some help may be offered in preoperative 
differentiation of adrenal adenoma and adrenal car- 
cinoma. 

Diagnostic Studies of Adrenocortical 
Function 

Measurement of the daily urinary excretion of 
1 7-hydroxycorticosteroids (the metabolites of hy- 
drocortisone) has proved to be a practical index of 
Cortisol secretion. Normal adults excrete 3 to 12 mg 
of 1 7-hydroxycorticosteroids (17-OHCS) in 24 
hours and patients with Cushing's syndrome usually 
excrete in excess of 12 mg per day. Occasionally 
large and active individuals excrete greater quanti- 
ties and children typically excrete smaller amounts. 
The accuracy of the urine collection and at the same 
time an adjustment for body weight can be obtained 
by relating the quantity of 17-OHCS to the quantity 
of creatinine in the urine. Normal individuals excrete 
3.0 to 8.0 mg and patients with Cushing's syndrome 
almost always excrete more than 10 mg of 
17-OHCS per gram of creatinine. All of the patients 
of our series had elevated urinary 17-OHCS levels; 
the seemingly low values in Cases 1 and 6 are ac- 
tually markedly elevated when related to grams of 
creatinine excreted in these small children. 

The relations between the adrenocorticotropic 
hormone (ACTH) of the pituitary and Cortisol in 
normal individuals and in patients with Cushing's 
syndrome have been studied extensively.*- - 8 ' 10 - 18 In 
the normal individual secretion of ACTH by the pi- 
tuitary governs the secretion of Cortisol by the 
adrenal cortex. Cortisol in turn has a suppressive 
effect on the secretion of ACTH. The ACTH-corti- 
sol relationship can be depicted as a servo-mecha- 
nism in which Cortisol levels tend to be self regulat- 
ing. In Cushing's syndrome the fact that Cortisol lev- 
els are elevated indicates that the normal restraint 
on pituitary or adrenal function is not operating prop- 
erly. Two possibilities are apparent: either the 
ACTH secreting mechanism is not restrained by 
normal levels of Cortisol or else the adrenal cortex is 
no longer dependent on the stimulatory effect of 
ACTH and secretes excessive Cortisol autonomously. 

The ACTH suppression test is based on the uri- 
nary 1 7-OHCS response to small doses of a potent 



synthetic steroid, A'-9a- fluorocortisol (AFF) or 
dexamethasone, which has 30 times the potency of 
Cortisol and which, like Cortisol, can suppress 
ACTH secretion by the pituitary. 9 In normal sub- 
jects 0.5 mg of AFF or dexamethasone every 6 
hours causes a drop in urinary excretion of 
17-OHCS to less than 2.5 mg per day in 48 hours. 
In our previously reported study 13 of 30 pa- 
tients with Cushing's syndrome, all who were tested 
showed abnormal resistance to the suppressive effect 
of this small dose of AFF. In 23 of 24 patients with 
adrenocortical hyperplasia, a larger dose of AFF or 
dexamethasone (2 mg every 6 hours) caused a sup- 
pression of the daily urinary output of 17-OHCS. 
This response indicates ACTH-dependent Cushing's 
syndrome. In patients with Cushing's syndrome due 
to an adrenocortical tumor, AFF and dexametha- 
sone in both small and large doses failed to cause 
suppression of urinary 17-OHCS output. This abso- 
lute resistance to suppression is also encountered in 
the "ectopic ACTH syndrome" of bilateral adrenal 
corticalhyperplasia induced by a nonendocrine tu- 
mor (certain carcinomas of lung, pancreas, etc.) 
which secretes ACTH or an ACTH-like polypep- 
tide. 11 Endocrinologic differentiation between Cush- 
ing's syndrome caused by an ectopic ACTH-produc- 
ing tumor and a tumor of the adrenal cortex which 
produces Cortisol autonomously can be made by 
measurement of the ACTH activity in the patient's 
plasma. In the ACTH-secreting tumors the patient's 
plasma ACTH activity is elevated, 11 while a low lev- 
el of plasma ACTH activity occurs in patients with 
Cushing's syndrome caused by adrenal cortical tu- 
mor. 3 

Other endocrine studies which are helpful in the 
diagnosis of Cushing's syndrome and in the differen- 
tiation between ACTH dependent adrenocortical hy- 
perplasia and adrenocortical tumor include the 
methopyrapone (SU-4885) test, the ACTH stimula- 
tion test and measurement of urinary 17-ketosteroid 
levels. The drug methopyrapone (Metopirone®) 
blocks 11 -beta hydroxylation in the adrenal cortex 
and thus impairs the conversion of compound S to 
Cortisol. When patients with Cushing's syndrome are 
tested with this drug, those with pituitary-dependent 
adrenocortical hyperplasia show an increased output 
of urinary 17-OHCS, while patients with the "ecto- 
pic ACTH syndrome" have a variable response and 
those with adrenocortical tumor fail to respond. 

These observations can be explained by the con- 



U.S. NAVY MEDICAL NEWS LETTER 



Table 2 



Results of Adrenocortical Function Studies and Surgical Treatment in 
15 Patients with Gushing' s Syndrome Due to Adrenal Tumor 













Urinary 17-Hydroxycorticoids 
















Urinary 




<mg./24 hr.) 
















2nd 


2nd 












17-Keto 




ACTH 


day 


day 
















Steroids 




50u. 


AFF 


AFF 














Age 


mg./ 




IV 


0.5 mg. 


2.0 mg. 


Tentative 


Operative 




Patient 


Sex 


(yr.) 


24 hr. 


Basal 


8 hr. 


q 6 hr. 


q 6 hr. 


Diagnosis 


Findings 


Result 


1. 


L. G. 


F 


% 


0.65 


6.15 


* 


* 


+ 


?Left carcinoma 


Left adenoma 


Excellent — 1 1 yr. 


2. 


L. J. 


M 


48 


33 


22 


26 


21 


20 


Left adenoma 


Left adenoma 


Excellent — 17 mo.** 


3. 


A. D. 


f 


49 


45 


17 


21 


20 


— 


Right carcinoma 


Right carcinoma 


Excellent — 8 yr. 


4. 


V. W. 


F 


57 


12 


23 


50 


23 


27 


Left adenoma 


Left adenoma 


Excellent — 6 yr. 


5. 


M. S. 


F 


39 


9 


18 


19 


19 


2(1 


Carcinoma 


Left adenoma 


Excellent — 6 yr. 


6. 


V. Me. 


F 


11 


72 


13 


18.5 


— 


24 


Right carcinoma 


Right carcinoma 


Hospital death 


7. 


P. C. 


M 


5 


16.4 


15.4 


12+ 


12 + 


9.5+ 


Right carcinoma 


Right carcinoma 


Excellent — 3 yr. 


8. 


B. L. 


F 


46 


10.5 


18.6 


89 


40.5 


33.0 


Right adenoma 


Right adenoma 


Excellent — 3 yr. 


9. 


D. R. 


F 


50 


27 


16.0 


78 


15 


14 


Adenoma 


Bilateral 
adenoma 


Excellent — 26 mo. 


10. 


L. T. 


F 


35 


26 


16.0 


32 


27 


26 


Right adenoma 


Right adenoma 


Excellent — 23 mo. 


11. 


M. S. 


F 


38 


11 


17 


14 


17.6 


20 


Carcinoma 


Right adenoma 


Excellent — 21 mo. 


12. 


E. R. 


M 


5! 


8 


25 


60 


20 


18 


Left adenoma 


Left adenoma 


Excellent — 17 mo. 


13. 


E. H. 


F 


63 


27 


11-121 


115 


35 


56 


Left adenoma 
? bilateral 


Right adenoma, 
bil. hyper- 
plasia 


Excellent — 2'A mo. 
then sudden death 


14. 


M. J. 


F 


44 


5.5 


22 


51. 


23 


22 


Left adenoma 
? bilateral 


Left adenoma 


Excellent — 6 mo. 


15. 


S. J. 


F 


38 


18 


8-24 


13.4 


17 


lg*** 


Right adenoma 


Right adenoma 


Excellent — 1 mo. 



•Not done. 
*»Died with intestinal obstruction 17 mo. later. 
***One week later spontaneous decrease to 1.6 mg./24 hr. 



cept that, in Cushing's disease with elevated pitui- 
tary ACTH output, pharmacologic blockage by the 
Metopirone® of Cortisol production in the adrenal 
cortex results in equivalent reduction of the restrain- 
ing influence which Cortisol has on the pituitary out- 
put of ACTH. Thus even more ACTH is produced 
by the pituitary, with a proportionate stimulus to in- 
creased steroid production by the adrenal cortex; in- 
creased production of compound S is the result and 
this is reflected by an increase in the urinary steroid 
end products which are measured as 17-OHCS. On 
the other hand when an adrenocortical tumor which 
secretes Cortisol autonomously is present, the pitui- 
tary production of ACTH is suppressed. If the 
Metopirone® is given and Cortisol production by 
the cortex is blocked, there is no corresponding re- 
sponse in ACTH output by the chronically sup- 
pressed pituitary and thus no rise in 17-OHCS re- 
sults. 9 The variability in response to Metopirone® 
in patients with the ectopic ACTH syndrome has 
been explained by Meador et al. 11 as probably being 
related to the variation in secretory rate of Cortisol 
in such cases and the corresponding variation in de- 
gree of responsiveness or suppression of the pitui- 
tary. 

The standard ACTH stimulation test offers 
further diagnostic information. In normal subjects 
the urinary 17-OHCS response to 8-hour infusion of 
50 units of ACTH is between 20 to 40 mg/24 
hours. In Cushing's syndrome due to adrenal hyper- 
plasia, in our previous experience, the basal levels 



were elevated and following ACTH infusion the lev- 
els increased to between 30 to 80 mg. In most in- 
stances, patients with adrenal hyperplasia responded 
by excreting more than 50 mg of 17-OHCS/24 
hours. On the other hand about half of the patients 
who proved to have adrenal adenoma have shown 
an increase in urinary 17-OHCS excretion following 
infusion of ACTH. Patients with adrenal carcinoma 
causing Cushing's syndrome are usually unrespon- 
sive to ACTH stimulation, although rare exceptions 
have been recorded. 

Clinical and Laboratory Data 

Table 2 summarizes the pertinent clinical and lab- 
oratory findings in 15 patients with Cushing's syn- 
drome due to adrenocortical tumor. In this series a 
diagnosis of an adrenal tumor was made preopera- 
tively in each instance. The prediction of whether a 
tumor was benign or malignant was not attempted 
preoperatively with realistic intent. However, on six 
occasions a preoperative diagnosis of adrenal corti- 
cal carcinoma was considered on the basis of unre- 
sponsiveness to exogenous ACTH. In three patients 
a carcinoma was found at operation and three pa- 
tients had benign adenomata. The reverse has not 
occurred; in every case in which a preoperative diag- 
nosis of benign adenoma was made from the endo- 
crine studies this proved to be correct. With cur- 
rently available tests those patients with benign 
adenoma who are not stimulated by ACTH infusion 
are indistinguishable endocrinologically from pa- 



10 



U.S. NAVY MEDICAL NEWS LETTER 



tients with adrenal cortical carcinoma. Another fea- 
ture of adrenocortical carcinoma is the frequent but 
not invariable elevation of basal 17-ketosteroid lev- 
els. Two of three patients with carcinoma in this 
series had such elevations. 

Preoperative lateralization of an adrenal tumor 
was accomplished in 12 of 15 cases. In two cases a 
large tumor was readily palpable (one carcinoma 
and one adenoma). Every patient had an intraven- 
ous pyelogram and intravenous pyelography served 
to lateralize the tumor in six instances. Retroperito- 
neal pneumography was reserved for cases in which 
the tumor was not accurately localized by pyelog- 
raphy or in which pyelographic results were only 
suggestive. In seven cases a tumor was accurately 
silhouetted in the retroperitoneal pneumogram with 
the additive help of tomography. In one patient the 
tumor was localized by combining pyelography and 
pneumography. In another, aortography delineated 
adrenal "tumor vessels" which led to a confirmatory 
retroperitoneal pneumogram. In the remaining three 
patients the tumor could not be localized by any 
preoperative study; large bilateral adenomata were 
present in one and small left adrenal adenomata in 
two. 

Surgical Treatment 

In the first seven patients a transabdominal ap- 
proach was used for removal of the adrenal tumor. 
In most of these patients a long transverse or "buck- 
et handle" incision was utilized. This was extended 
across the costal margin into a lower intercostal 
space in three patients with large tumors. 14 In the 
remaining patients we preferred to use the posterior 
retroperitoneal approach to the adrenal in patients 
with adrenocortical tumors causing Cushing's syn- 
drome, except when carcinoma has been suspected 
preoperatively or when anesthetic factors argue 
against the prone position. We believe that the pos- 
terior retroperitoneal approach is associated with 
less postoperative morbidity than is a transabdomi- 
nal procedure. After induction of anesthesia and intu- 
bation the patient is positioned in the prone decu- 
bitus with the table broken at the hips and a firm 
pillow under the abdomen. Careful bilateral postero- 
lateral incisions of the Hugh Young type are made 
and each adrenal fossa is explored simultaneously, 
usually through the bed of the 11th rib. Excellent 
exposure of each adrenal is provided by this ap- 
proach. The possibility of bilateral adenoma, as 
emphasized by Hayes, 5 is accurately confirmed or ex- 
cluded. Biopsy of the normal or atrophic adrenal con- 
tralateral to a single cortical tumor provides corrobo- 



rative histologic information and a more accurate ap- 
praisal of the anatomic status of the glands but is of 
limited value in predicting the functional status of 
adrenocortical tissue. However it is a sound prin- 
ciple to make an accurate appraisal of the gross 
status of each adrenal gland before making a deci- 
sion to remove one or both glands. In patients sus- 
pected of having an adrenocortical carcinoma we 
prefer to use the anterior abdominal approach with 
a thoraco-abdominal extension so as to permit a per- 
formance of a radical nonmanipulative resection. 

Table 2 summarizes our surgical experience with 
adrenal tumors which cause Cushing's syndrome. 
Three of these patients had an adrenocortical carci- 
noma, ten had unilateral adenoma and one had bilat- 
eral adenomata. Another patient with a solitary 
adenoma had coexistent bilateral adrenocortical hy- 
perplasia. The patient (Case 9) with bilateral ade- 
nomata had a moderately severe Cushing's syndrome 
and deserves special comment because her specific 
pathophysiologic process may possibly represent a 
separate disease process. On endocrinologic evalua- 
tion this woman had Cushing's syndrome with re- 
sponses to dexamethasone suppression and ACTH 
stimulation which suggested a benign adrenal ade- 
noma rather than bilateral adrenocortical hyperplasia. 
Her plasma ACTH levels were low. Preoperative 
efforts at lateralization of a tumor were equivocal 
and the diagnosis was adrenocortical adenoma with- 
out lateralization. Bilateral adrenal exploration 
showed large (70 Gm) adrenocortical tumors on 
each side. These were removed totally and histologi- 
cally their cellular structure suggested bilateral hy- 
perplasia rather than tumor — this histologic differen- 
tial, however, is difficult at best. The microscopic 
sections of the tumors in this patient were reviewed 
by several pathologists including Dr. Malcolm Dock- 
erty at Mayo Clinic; the distinction between benign 
adenoma and hyperplasia becomes very difficult in 
certain cases and in this particular situation the con- 
sensus of opinion was that the lesion should be clas- 
sified according to its functional behavior rather 
than its purely anatomic aspects. Accordingly, a 
diagnosis of bilateral adrenocortical adenomata was 
made. It should be kept in mind, however, that an 
alternative diagnosis in this unique situation might 
be a primary bilateral adrenocortical hyperplasia 
without dependence on ACTH stimulation, either of 
pituitary or ectopic origin. 

In this series of 15 patients the tumor was re- 
moved successfully in each instance with a single ex- 
ception — a child (Case 6) with a massive right 
adrenal carcinoma which involved the kidney, liver, 



U.S. NAVY MEDICAL NEWS LETTER 



11 



inferior vena cava, aorta and retroperitoneal lymph 
nodes. This patient died in the early postoperative 
period following a very radical resection. Operative 
and postoperative complications in the 14 surviving 
patients included one patient who developed a 
wound infection, another who had a transient pleu- 
ral effusion and a third who developed hepatitis 6 
weeks after operation and made a good recovery 
with steroid therapy; operative injury to a ureter was 
recognized and repaired successfully in another pa- 
tient and no residual uropathy resulted. 

Inasmuch as adrenocortical tumors which cause 
Cushing's syndrome are autonomous, the patient's 
normal adrenal tissue becomes relatively atrophic 
and nonfunctional. Following removal of the adrenal 
tumor in this series of patients, a careful regimen of 
adrenal substitution therapy was instituted. In addi- 
tion, in the early postoperative period brief courses 
of ACTH therapy were given to stimulate the re- 
sumption of secretory function by the remaining 
adrenal tissue. In occasional instances adrenal sub- 
stitution therapy was required for as long as 1 to 2 
months. In most cases, however, in which unilateral 
adrenalectomy was performed, adrenal substitution 
therapy was required for only a few days. 

The follow-up period in the surviving patients 
now extends from 1 month to 11 years. In general, 
the prominent stigmata of Cushing's syndrome have 
disappeared. The florid manifestations have re- 
gressed quite promptly; however, a complete return 
to a "normal" status may require several months. 
Severe osteoporosis and marked mental changes are 
seldom completely reversible. One patient (Case 
13) died at home, suddenly, of unexplained cause 
IVz months after apparently successful surgical 
treatment. Another patient (Case 2) died of intes- 
tinal obstruction 17 months following excision of an 
adenoma; he had been completely relieved of the 
Cushing's syndrome in the interval. One patient 
(Case 5) has persistent hypertension and impaired 
glucose tolerance but is otherwise well. The other 12 
patients have been relieved of the Cushing's syn- 
drome; however, two have intermittent psychiatric 
problems. The two surviving patients who had 
adrenal carcinoma have been followed 3 and 8 
years, respectively, and have no evidence of residual 
tumor. 

Comment and Summary 

Fifteen patients with Cushing's syndrome due to 
adrenocortical tumor have been studied and treated 
surgically during the past 1 1 years. Many of the pa- 



tients presented with only a few of the classic clini- 
cal manifestations, and precise studies of adrenocor- 
tical function were often required to establish the 
diagnosis. Through these studies it was possible to 
determine with accuracy that the Cushing's syn- 
drome was the result of adrenal tumor rather than 
bilateral adrenal hyperplasia secondary to pituitary 
or ectopic ACTH overproduction, A precise pre- 
operative diagnosis of adrenal carcinoma was made in 
three patients. In 12 patients with a benign function- 
al adenoma, a preoperative diagnosis of adrenal 
tumor was made in each instance, and on eight occa- 
sions it was possible to designate the tumor accu- 
rately as an adenoma. In the other three cases of 
benign adenoma, the preoperative studies indicated 
adrenal tumor but did not allow endocrinologic dif- 
ferentiation between carcinoma and adenoma. 
There was no strong reliance on preoperative endo- 
crinologic efforts to differentiate between adrenal 
carcinoma and adrenal adenoma. This study, how- 
ever, demonstrated that preoperative endocrinolo- 
gic differentiation between adrenocortical tumor and 
hyperplasia has achieved great reliability. Localiza- 
tion of the tumor was accomplished before operation 
by physical examination arid radiologic studies in 12 
of 15 patients. Failure to localize the adrenal tumor 
with accuracy prior to operation in three patients, 
coupled with the frequency of bilaterality of adrenal 
pathology in Cushing's syndrome, has prompted us 
to expose each adrenal gland routinely at operation. 
The bilateral posterior approach to the adrenals pro- 
vides adequate exposure with less postoperative 
morbidity than the anterior incisions which we re- 
serve for cases in which carcinoma is suspected. 

Successful surgical treatment was accomplished in 
14 of 15 patients. Following removal of the tumor 
the regression of the syndrome is rapid and com- 
plete. 

REFERENCES 

1. Anderson, E., W. Haymaker and M. Joseph: Hormonal and 
Electrolyte Studies of Patients with Hyperadrenocortical Syn- 
drome (Cushing's Syndrome). Endocrinology 23: 398, 1938. 

2. Cushing, H.: The Basophil Adenomas of the Pituitary Body 
and Their Clinical Manifestations. Bull Johns Hopkins Hosp 
50: 1.37, 1932. 

3. Graber, A. L., R. L. Ney, W, E. Nicholson, D. P. Island and 
G. W. Liddle: Natural History of Pituitary-Adrenal Recovery 
Following Long-Term Suppression with Corticosteroids. Trans 
Assn Amer Physicians, 19&1. p 296. 

4. Grumbach, M. M., A. M. Bongiovanni, W. R. Eberlein, J. J. 
Van Wyk and L. Wilkins: Cushing's Syndrome with Bilateral 
Adrenal Hyperplasia: A Study of the Plasma 17-Hydroxycorti- 
costeroids and the Response to ACTH. Bull Johns Hopkins Hosp 
96: 116, 1955. 

5. Hayes, M. A.: Personal Communication. 

6. Jenkins, J. S. and A. W. Spence: Effect of Corticotropin and 
9 a-Fluorohydrocortisone on Urinary Steroids in Cushing's Syn- 
drome. J Clin Endocr 17: 621, 1957. 

7. Laidlow, J. C, W. J. Reddy, D. Jenkins, N. Abu Haydar, A. E. 
Renold and G. W. Thorn: Advances in the Diagnosis of Altered 
States of Adrenocortical Function. New Eng J Med 253: 747, 
1955. 

8. Liddle, G. W. : Tests of Pituitary-Adrenal Suppressibility in the 
Diagnosis of Cushing's Syndrome. J Clin Endocr 20: 1539, 1960. 



12 



U.S. NAVY MEDICAL NEWS LETTER 



9. Liddle, G. W„ H. L. Estep, J. W. Kendall Jr., W. C. Williams 
Jr. and A. W. Townes: Clinical Application of a New Test of 
Pituitary Reserve. J Clin Endocr 29: 875, 1959. 

10. Liddle., G. W., D. Island and C. K. Meador: Normal and Ab- 
normal Regulation of Corticotropin Secretion in Man. Recent 
Prog. Hormone Res 18: 125, 1962. 

11. Meador, C. K., G. W. Liddle, D. P. Island, W. E. Nicholson, 
C. P. Lucas, J. G. Nuckton and J. A. Luetscher: Cause of Cush- 
ing's Syndrome in Patients with Tumors Arising from "Nonendo- 
crine" Tissue. J Clin Endocr 22: 693, 1962. 



12. Nabarro, J. D. N., A. Moxham and G. Walker: Stimulation and 
Suppression of the Adrenal Cortex in Cushing's Syndrome. J Clin 
Endocr 18: 586, 1958. 

13. Scott, H. W. Jr., G. W. Liddle, A. P. Harris and J. H. Foster: 
Diagnosis and Treatment of Cushing's Syndrome. Ann Surg 155: 
696, 1962. 

14. Scott, H. W. Jr. and J. H. Foster: Surgical Considerations in 
Hypertension. Current Problems in Surgery, Year Book Medical 
Publishers. Chicago, 111., July 1964. 



PHYSICAL FITNESS IN THE READY RESERVE 
CDR B. G. Clarke MC USNR(Ret)* 



All personnel of the naval service, regular or re- 
serve, 1 are directed 2 to be "in a state of physical fit- 
ness to be prepared immediately to perform duties 
for periods requiring long endurance under the most 
trying conditions." For Marines, 3 "it is essential to 
combat effectiveness that every Marine", regular or 
reserve, be physically fit. "A minimum of 2 1 /2 hours 
weekly is required to develop and maintain an ade- 
quate level of physical fitness through vigorous activ- 
ity." 

To determine the level of fitness among reservists 
a study was made of 509 Marine infantry or combat 
engineer troops. All were undergoing annual field 
training at an Amphibious Training Command 
during late June and early July, 1965. 18 were 
officers; 39 were sergeants (E-5 to E-9); and 452 
were in lower enlisted ranks. They were members of 
Organized Reserve units located in five eastern or 
midwestern cities ranging in size from 80,000 to 
200,000 and in one eastern metropolis. 

Results 

Comparatively few of these men were found to 
engage regularly in sports or physical conditioning 
exercises or to be employed in occupations which 
might be expected to contribute to development of 
physical strength or stamina. 

Six percent of the reservists habitually engaged 
once a week or more often in a sport or sports ap- 
propriate to the season the year around. Sports par- 
ticipation during a part of the year was reported by 
42 percent of the men from the five smaller cities; 
23 percent of the men from the metropolis; and 39 
percent of all 509 men. 

Twelve percent habitually engaged in physical 
conditioning exercises, including running, three 



* Appropriate Duty Medical Officer, Co. D, 6th Engineer Bn., Force 
Troops, FMF, USMCR and USNR Group 9-72 (S), Peoria. Asst 
Professor of Urology, Northwestern University Medical School, 
Chicago, Urologist, St. Francis Hospital, Peoria. 



times a week or more often which is the minimum 
required for effect. 4 

Twenty percent of all individuals studied were 
employed in occupations which the investigator be- 
lieved likely to contribute to development of physi- 
cal fitness. 

Performance of men was observed while they 
climbed debarkation nets and traversed an obstacle 
course. On the latter, the average reservist was able 
to get through 18 of 24 obstacles. 32 percent of the 
men traversed all 24 of the obstacles. 

Poor performance on debarkation nets and the 
obstacle course was displayed by a large proportion 
of men who appeared overweight or were over- 
weight by Department of Defense standards. 5 All 
509 of the men were actually weighed during the 
study. Only 1.4 percent were overweight according 
to standard tables for height and age 5 but many 
more looked obese and performed poorly. A very 
small proportion of overweight individuals are ex- 
tremely muscular and are likely to perform well. 6 

A surprisingly high proportion of reservists were 
subject to physical disabilities resulting from civilian 
activities during the year which preceded annual 
field training,, and which disqualified them for mili- 
tary duty. A company with average annual strength 
of 100 men was studied in detail in this connection. 
During the year 50 men left the company for non- 
medical reasons and were replaced. 14 more men, 
during the same year, developed physical disabilities 
of non-military origin which disqualified them for 
military duty and required 1 their temporary or per- 
manent transfer out of the Ready Reserve. Most dis- 
qualifications resulted from sports injuries and auto 
accidents. A few were due to industrial trauma and 
a few to illnesses of non-traumatic origin. 

Most of the reservists studied did not have civilian 
occupations or habits of sports participation and ex- 
ercise which promote physical fitness. The need was 
shown for reservists to improve their strength and 



U.S. NAVY MEDICAL NEWS LETTER 



13 



stamina by engaging in sports and in habitual, pro- 
gressive, individual exercise programs 4 ' s_1 °. The 
study confirmed the opinion 4 that "modern technol- 
ogy has lessened the opportunity for obtaining suffi- 
cient daily physical activity to maintain adequate 
muscle tone." 

Men who were absolutely"' or relatively over- 
weight tended to perform poorly in arduous events. 

During the year preceding annual field training, 
1 4 percent of the average strength of a group which 
was studied developed physical disabilities of non- 
military origin, which disqualified them for military 



duty and required their temporary or permanent 
transfer out of the Ready Reserve. 

REFERENCES 

I. SUPERS INST 6100.2B, 14 Nov 1964. 

2. SECNAV INST 6100.1. 14 Aug 1%L 

3. MARINE CORPS ORDER 6100.3D, 18 Mar 1965. 

4. Guild, Warren R.: How to Keep Fit and Enjoy It. New York, 
Harper & Brothers, 1962. 

5. Manual of the Medical Department, U.S. Navy, 15-72, app. III. 

6. Personal correspondence, Naval Medical Field Research Labora- 
tory NMFRL-t-3-PJR:vg, 3900-7, ser. 528, 28 Jun 1965. 

7. Manual of the Medical Department, U.S. Navy, Chapter 15. ' 

8. Special Report: Exercise and Fitness. A Statement on the Role 
of Exercise in Fitness by a Joint Committee of the American 
Medical Association and the American Association for Health, 
Physical Education, and Recreation. JAMA 188: 433, May 4, 
1964. 

9. Department of the Army Field Manual FM 21-20: Physical 
Training, Oct 1957. 

10. Department of the Army Technical Manual TM 21-200: Physical 
Conditioning, Dec 1957. 



FROM THE NOTE BOOK 



IMPLANTABLE ELECTRONIC PACEMAKERS 

The more than 10,000 American heart patients 
who have been fitted with implantable electronic 
pacemakers need have no fear that the pacemaker 
will be affected by proximity to diathermy machines, 
neon signs, household appliances, radios, TV sets, or 
other electrical or electronic apparatuses that gener- 
ate radiofrequency emissions, the Public Health Serv- 
ice's National Heart Institute, U.S. Department of 
Health, Education and Welfare, said. 

The Institute said that implantable electronic 
pacemakers manufactured and commercially avail- 
able in the United States have been repeatedly test- 
ed and found completely free of susceptibility to 
outside radiofrequency interference. 

"These tests have shown that, once the pacemaker 
is implanted within the patient's body, its. electronic 
design and the natural shielding afforded by body 
tissues prevent any external radiofrequency sources 
from affecting its performance," Dr. Peter Mansfield 
of the Institute's Laboratory of Cardiovascular Phys- 
iology said. 

The Institute's statement was prompted by a re- 
cent paper published in the British Medical Journal 
which received wide publicity in the United States. 
Most of the publicity failed to indicate that the ar- 
ticle's findings of radiofrequency interference ap- 
plied only to two pacemakers of foreign manufac- 
ture — one external and one implantable — and not to 
implantable pacemakers manufactured in the United 
States. 

Electronic pacemakers generate electrical signals 
that cause the heart to beat at a normal rate in pa- 
tients whose normal pacemaker function has been 



disrupted by heart disease or operative injury. Those 
currently in clinical use in the U.S. are completely 
implantable and are powered by long-life batteries 
that need replacement only every few years. These 
devices have saved thousands of lives and have en- 
abled other thousands of heartblock victims to re- 
sume active lives, the Institute said. 

The National Heart Institute is one of the nine 
National Institutes of Health of the Public Health 
Service, USDHEW— HEW-G14, July 27, 1965. 

STUDIES ON MURINE LEUKEMIA 

Rich, Marvin A., Albert Einstein Medical Center, 

Philadelphia, Geldner, Janice, and Meyers, Paul. 

J Nat Cancer Inst 35(3): 523-536, September 

1965. 

A virus capable of inducing leukemia in rodents is 
described. The agent, morphologically similar to 
other murine leukemia viruses, induced lymphoid 
leukemia in a variety of mouse strains and in Os- 
borne-Mendel rats. Although leukemogenic activity 
was inversely proportional to age, Swiss mice up to 
6 months of age could be infected. Measurable in- 
fectivity could be demonstrated after exposure to 
56°C for up to 1 hour. Virus was inactivated by for- 
malin and ethyl ether. The virus could be propagat- 
ed in cell cultures of mouse embryo without cyto- 
pathogenicity. Comparison with Moloney leukemia 
virus by the cell-specific antigen technique suggested 
antigenic differences. Cytotoxicity tests indicated that, 
unlike the Friend, Moloney, Rauscher, and Gross vi- 
ruses, the virus described here shared cytotoxic anti- 
gens with all the other four. Vaccines prepared with 
this or Friend virus protected mice from the leuke- 
mogenic activity of this virus. Low concentrations 



14 



U.S. NAVY MEDICAL NEWS LETTER 



(1,256) of antisera prepared against this virus neu- 
tralized high titers of virus. Cross reactivity with 
Moloney, Friend, and, to a lesser extent, Rauscher 
virus was observed. The current status of the rela- 
tionship between the murine leukemia viruses is dis- 
cussed. 

RECOVERING THE USE OF 
PARALYZED LIMBS 

A new phase of a research project aimed at find- 
ing a way for people to recover the use of paralyzed 
arms and legs is under way at the Case Institute of 
Technology in Cleveland, Ohio. 

The Vocational Rehabilitation Administration of 
the U.S. Department of Health, Education, and Wel- 
fare expects to make grants totaling approximately 
$1,000,000 to help support the project over the next 
five years, Miss Mary E. Switzer, Commissioner of 
Vocational Rehabilitation, announced. 

The VRA grant for the first year will be approxi- 
mately $200,000. Case Institute's share for the same 
period will be about $95,000. 

Case Institute scientists hope to transmit electric 
impulses from a computer-tape recorder system to 
tiny receivers implanted in the muscles of a para- 
lyzed limb, the purpose being to activate the 
muscles. For example, a person with a paralyzed 
arm would give a signal to the tape recorder and 
thus be able to put his arm through such motions as 
lifting a glass of water, brushing his hair, or cleaning 
his teeth. 

In the first phase of the project, Case Institute 
researchers developed a means of maneuvering an 
arm encased in a metal splint framework by sending 
electric impulses from a tape recorder to motors in 
the framework. Now the Case scientists hope to di- 
rectly activate paralyzed arms and legs. 

Both phases of the project have been directed by 
James B. Reswick, Professor of Engineering and 
Director of the Engineering Design Center at Case 
Institute.— HEW-G3 6, Aug 13, 1965. 

ACCURACY OF ROENTGENOLOGIC 
EXAMINATION IN DETECTING CARCI- 
NOMA OF THE COLON 

/. D. Lauer, H. C. Carlson, and E. E. Wollaeger. Dis 

Colon & Rectum 8: 190-197, May-June 1965. From 

Mayo Clinic Proceedings 40(9): 734, Selected 

Abstracts, September 1965. 

A study undertaken to determine the accuracy of 



barium-enema examination in detecting carcinoma 
of the colon was divided into two parts: (1) to de- 
termine the accuracy of barium-enema examinations 
in cases of proved carcinoma of the colon and 
(2) to determine the likelihood of false-positive 
reports of carcinoma based on such examinations. 
Of 707 cases in which lesions histologically proved 
to be carcinoma of the colon were located above the 
region of proctoscopic visualization, the lesion was 
either missed of misdiagnosed in 49 cases, an overall 
diagnostic error of 6.9%. If one excludes those car- 
cinomas found but misinterpreted, those associated 
with chronic ulcerative colitis, and those recurring at 
anastomoses, the diagnostic accuracy in this series 
was 95.9%. Of 577 cases in which a roentgenologic 
diagnosis of carcinoma of the colon was made, false- 
positive diagnoses were made in five cases, an error 
of 0.87%. The difficulties in detecting carcinoma of 
the colon by barium-enema examination are dis- 
cussed. The overwhelming majority of the lesions 
missed were located either in the cecum or the sig- 
moid colon. 

TESTING FOR DIABETES 

More than 700,000 Americans were blood tested 
for diabetes in fiscal year 1964 and almost a million 
persons will be tested during the fiscal year 1965, 
the Public Health Service, U.S. Department of 
Health, Education, and Welfare, reported- 

The Service said that the 705,324 persons who 
were screened during fiscal year 1964 represented an 
increase in screening of 34 percent over fiscal year 
1963. It estimated that there will be a similar in- 
crease during fiscal year 1965. 

Despite the increase in screening, an estimated 2 
million persons still have undetected diabetes, ac- 
cording to Dr. Glen W. McDonald, Chief of the Dia- 
betes and Arthritis Program, Division of Chronic 
Diseases. Dr. McDonald and his staff compiled the 
data based on screening results reported to the Serv- 
ice by 33 States and Puerto Rico. 

The data showed that during fiscal year 1964, the 
proportion of people who screened positive to the 
test remained almost the same as in 1963 — 44 per- 
sons per 1,000 tested. The rate of new cases also 
remained about the same as in fiscal year 1963 — 8.6 
per 1 ,000 persons tested. 

While the number of people who were screened 
increased dramatically, Dr. McDonald stressed that 
screening programs throughout the United States 



U.S. NAVY MEDICAL NEWS LETTER 



15 



should place increased emphasis on testing older 
people, the overweight, those with a family history 
of diabetes, and those with symptoms of diabetes. 

"Since approximately one-half of the diabetics in 
this country are undiagnosed, it is essential to con- 
centrate on screening those groups that will produce 
the greatest number of cases," he said. — HEW-F80, 
June 30, 1965. 

NAVAL MEDICAL RESIDENCIES TO 
START EARLIER 

The Bureau of Medicine and Surgery is desirous 
that most of its medical officers begin their residen- 
cies earlier in the year than has been the case in the 
past. Late starting has resulted from general short- 
age of medical officers, the difficulty in having re- 
liefs report early and the deployment of combat 
ships or units. 

The late arrival of specialists who have just com- 



pleted residencies has sorely taxed the ability of the 
activities to which they are reporting in accomplish- 
ing their missions. A resident finishing late has been 
confronted with problems in relation to children 
changing schools, inability to obtain certain desired 
billets, and in some cases, inability to obtain govern- 
ment quarters due to late arrival. 

BUMED intends to take aggressive action to 
solve this problem along the following lines: 

(1) Commanding Officers will be urged to re- 
lease prospective residents early, not waiting for re- 
lief unless absolutely necessary. 

(2) BUMED will select reliefs for prospective 
residents on the basis of early availability. 

(3) Orders into residencies will authorize a mini- 
mum of leave in route. 

(4) Future residents will be urged to take a mini- 
mum of the leave authorized prior to reporting. 



DENTAL SECTION 



Naval Dental Research Reports 

Abstracts of the 11th and 12th report of the 
Navy's intramural research program, delivered at the 
43rd General Meeting of the International Associa- 
tion of Dental Research, are reproduced here with 
permission of the Editor, Journal of Dental Re- 
search. The first of these two reports relates to ab- 
stract (5) of this series. T. S. Meyer, M.S. (Biochem- 
istry), and B. L. Lamberts, Ph.D. (Biochemistry), 
are civilian scientists on the staff of the Dental Re- 
search Facility, Great Lakes. CAPT P. J. Boyne, 
DC USN, is studying the use of preserved tissues in 
oral surgery. Having previously served at the U.S. 
Naval Dental School and as a guest scientist at the 
Naval Medical Research Institute, CAPT Boyne re- 
cently completed a tour of duty as Dental Officer in 
the USS BON HOMME RICHARD. In May 
1965, he assumed his new duties as Head of the 
Dental Department, Naval Medical Research Insti- 
tute. In the subject report, Dr. Jaime Yrastorza col- 
laborated with CAPT Boyne under support of an 
Office of Naval Research grant, while a graduate 
student at Georgetown University. Dr. Yrastorza, an 
oral surgeon, is currently practicing in Colorado. 



A COMPARISON OF VARIOUS STAINS 

FOR HUMAN PAROTID SALIVA PROTEINS 

SEPARATED BY ACRYLAMIDE GEL 

ELECTROPHORESIS 

T. S. Meyer and B. L. Lamberts, Dental Research 
Facility, Great Lakes, Illinois. 

Various stains were compared with the commonly 
used amidoblack 10B in an effort to improve the 
visualization of parotid saliva proteins separated by 
acrylamide gel electrophoresis. The following stains 
were tested: Aniline Blue, Aniline Blue Black, Azo- 
carmine G, Bromphenolblue, Coomassie Brilliant 
Blue, Light Green SF, Nigrosis, Ponceau R, Pon- 
ceau S, Procion Brilliant Blue, and Wool Fast Blue 
BL. The comparisons were made on individual or 
pooled collections of paraffin-stimulated parotid sa- 
liva from healthy naval male recruits and on crystal- 
line parotid saliva amylase. All electrophoresis ex- 
periments were performed in 5 percent acrylamide 
gel with 0.1 M Tris-EDTA-boric acid buffer at PH 
9.0. The finished gel was treated with a 0.02, 0.1, 
0.5 or 1.0 percent solution of the stain in a mixture 
of methanol, water, and glacial acetic acid (5:5:1) 
and the excess stain was removed either by rinsing 
with the same solvent blend or electrophoretically 
with 3.75 percent acetic acid. Wool Fast Blue and 



16 



U.S. NAVY MEDICAL NEWS LETTER 



Coomassie Brilliant Blue greatly improved the visual- 
ization of the electrophoretic patterns of cathodi- 
callyrmigrating proteins. These stains also permitted 
electrophoresis with much lower concentrations of 
parotid saliva proteins than is normally required for 
amidoblack 10B. 

OSSEOUS REPAIR OF THE POST EXTRAC- 
TION ALVEOLUS IN MAN 

Philip J. Boyne and Jaime Yrastorza, Naval 

Medical Research Institute, Bethesda, Md., 

and Wheatridge, Colo. 

Recent fluorescent microscopic investigations of 
post-extraction healing in dogs have demonstrated 
the existence of hitherto unreported osseous repair 
phenomena occurring in "extra-alveolar" areas. The 
purpose of this study, was to observe histologically 
by means of tetracycline induced fluorescence, the 
osseous repair phenomena associated with healing of 
the human post-extraction alveolus. Twelve clinical 
patients presenting for full maxillary tooth extrac- 
tion were selected for this study. One maxillary first 
bicuspid was removed in each patient. At selected 
postoperative intervals tetracycline was administered 
to the patients in order to chronologically orient the 
osseous healing processes. At the time of extraction 
of all remaining maxillary teeth biopsies were taken 
containing the entire bicuspid socket with the sur- 
rounding bone. Bony defects were grafted with 
freeze-dried homogenous bone to restore contour. 
Ground undecalcified sections were studied by ultra- 
violet microscopy. Tetracycline labelling at 7 days 
postoperatively demonstrated marked new bone for- 
mation in the marrow vascular spaces but no os- 
seous matrix in the socket itself. The first evidence 
of bone formation associated with alveolar healing 
occurred along the endosteal side of the lamina 
dura. The first bone formation in the socket itself 
occurred 9 days after extraction. Initial new bone 
matrix in the alveolus was observed along the lateral 
aspect of the socket and not in the fundus as fre- 
quently described. The results of this study would 
indicate that various extra-alveolar and intra-alveo- 
lar repair phenomena observed in experimental ani- 
mals also occur in man. 

DENTAL PULP HEMOGRAM 

Guthrie, T. J., McDonald, R. E., and Mitchell, 

D. F., Jour Den Res 44(4): 678-682, 

July-Aug 1965. 

On the basis that the degree of success of vital 
pulp therapy can be increased by more critical selec- 



tion of cases, it becomes of paramount importance 
to know the status of the pulp one is attempting to 
treat by pulp capping or pulpotomy. This study was 
designed to compare the commonly used clinical 
diagnostic methods with the pulpal white blood cell 
differential count, as measures of the true status of 
the pulp in a tooth with an extensive carious lesion. 
The local pulp hemogram was compared with the 
histologic picture of the same pulp tissue, and with a 
sample of peripheral finger blood. Fifty-three teeth 
with carious pulp exposures were compared with 
fourteen normal teeth used as controls. Before oper- 
ative procedures, the history of past pain or discom- 
fort was recorded. In pulp testing procedures, ice 
was used to determine hypersensitivity to cold, hot 
temporary stopping (131° F) was used to detect hy- 
persensitivity to heat, and an electric unipolar vitality 
tester was used. Response to percussion and mo- 
bility were also recorded. Under rubber dam isola- 
tion, caries was excavated with spoon excavators 
and large round burs. The exposure size and amount 
of hemorrhage were recorded. The first drop of pulp- 
al blood and a drop from the pricked finger were 
stained with Wright's stain, and differential white 
blood cell counts were recorded. Then the teeth 
were extracted for histological study. 

On the basis of histological findings, the teeth 
were classified into 28 "good risks" and 25 "poor 
risks" for vital pulp therapy. The preoperative diag- 
nostic findings and the hemograms were correlated 
with those histological interpretations of the status 
of the pulp. 

No clear-cut relationship was observed between 
the dental pulp hemogram and the extent of pulp 
pathosis. However, some degree of relationship was 
observed between an elevated pulp neutrophil count 
and microscopic evidence of pulpal inflammation. 
The presence in the pulp hemogram of neutrophils 
exhibiting degeneration and karyolysis appeared to 
be indicative of extensive pulp inflammation, as was 
also the occurrence of profuse bleeding at the expo- 
sure site. No reliable diagnostic relationships were 
found in heat, cold, electrical, percussion, or mobil- 
ity tests relative to the degree of pulpitis. A history 
of spontaneous pain was a more reliable character- 
istic of extensive pulpitis than was a history of pain 
while eating. Teeth with a history of pain at night 
showed a considerable degree of pulpal inflamma- 
tion. 



U.S. NAVY MEDICAL NEWS LETTER 



17 



CORRECTION AND ADDITIONAL 
EXPLANATION 

In U.S. Navy Medical News Letter 46(6): 15, of 
24 September 1965, a regrettable typographic omis- 
sion occurred. In the abstract titled "Clinical Eval- 
uation of Stannous Fluoride in Naval Personnel," on 
line (10) of paragraph (2), between the words "re- 
ceived" and "a", the following should be inserted: 
"treatment with the SnF 2 prophylactic paste. Groups 
A, B and E received". This experimental design is 
presented more clearly in the table below. In the 
prophylaxis paste and topical solution, NaCl was 
used as placebo for SnF 2 , for reason of their similar 



strong salt taste. NaCl was not used as placebo in 
the control dentifrice because the two dentifrices 
were indistinguishable by taste and appearance. 

Experimental Design 



Group 


Prophy 


Topical 


Dentifrice 


A 


SnF 2 


4" SnF 2 


SnF 2 


B 


SnF 2 


4" SnF 2 


Placebo 


C 


SnF 2 


4" NaCl 


SnF 2 


D 


SnF 2 


4" NaCl 


Placebo 


E 


SnF 2 


15' SnF 2 


SnF 2 


F 


NaCl 


4" NaCl 


Placebo 



PERSONNEL AND PROFESSIONAL NOTES 



AMERICAN DENTAL DIRECTORY, DESIG- 



NATION OF CHARACTER OF PRACTICE. 

At its April, 1965 session, the Board of Trustees, 
American Dental Association approved a revised 
program for the listing of specialists in the 1966 edi- 
tion of the Directory. At its September, 1965 ses- 
sion, the Board of Trustees approved the following 
resolution: Resolved, that the implementation of the 
April, 1965 directive of the Board of Trustees for 
the listing of specialists in the 1966 issue of the A mer- 
ican Dental Directory be delayed until the 1967 
issue in order to permit the constituent and compo- 
nent societies to complete their portions of the listing 
program. 

The above points have been incorporated in a re- 
vised "Statement of Eligibility" form. Dental officers 
who desire to be listed as in limited practice, within 
the above policy, may request copies of these forms 
by letter to Chief, Bureau of Medicine and Surgery 
(Code 611). 

Additionally, a decision of the Judicial Council 
and requests from constituent societies have led to 
further revisions of the program which were also ap- 
proved by the Board of Trustees at the September, 
1 965 meeting: 

1. The Judicial Council at its last meeting re- 
versed its previous position that it is impossible for 
dentists in the Federal Dental Services to limit prac- 
tice. The Council now agrees that it is possible for a 
dentist to establish his eligibility for announcement 
of a limited practice while in the Federal Dental Serv- 
ices. The Council stated that it believes Section 18 of 
the Principles of Ethics has equal application to the 
dentist in the Federal Dental Service and the civilian 



dentist. The revised policy for listing character of 
practice in the Directory will, therefore, include all 
dentists in the Federal Dental Services who meet the 
qualifications and whose applications are signed by 
the Chiefs of Federal Dental Services. The "State- 
ment of Eligibility for Listing Character of Practice 
in the American Dental Directory" will now provide 
for branch of Federal Dental Service and signature 
of Chief-of-Branch. 

2. As there has been some objection by constit- 
uents to "certifying" eligibility for listing, and as it 
is the intent of the revised policy that primary re- 
sponsibility for notification and certification must lie 
with the individual dentists, the "Statement of Eligibil- 
ity" form has been revised to state. . . "It is hereby 
certified by the above dentist. . ." Because this Asso- 
ciation must deal with its membership through the 
societies having jurisdiction over the areas of prac- 
tice, the signatures of constituent and component sec- 
retaries insure that they have had opportunity to 
inspect each statement. 

3. Because the listing of dentists who qualify on 
the basis of ethical announcement of limitation of 
practice prior to December 31, 1964, may present 
some future administration problems, a time limit 
has been established for accepting applications for 
listing under this qualification. After December 31, 
1967, no further applications on the basis of that 
qualification will be accepted. This time-limit will al- 
low two years for all dentists in this situation to re- 
quest listing. 

4. It was established that the right of this Asso- 
ciation to request "proof of eligibility" is a reason- 



18 



U.S. NAVY MEDICAL NEWS LETTER 



able condition and may assist in the administration 
of the policy for listing in the Character of Practice 
section of the American Dental Directory. 

NAVY PARTICIPATION IN ADA AND AS- 
SOCIATED PROFESSIONAL MEETINGS. At 
the 106th Annual Session of the American Dental 
Association, 8-11 November 1965, at Las Vegas, 
Nevada, RADM F. M. Kyes, and CAPT W. Naish 
served as Navy Delegate and Alternate, respectively, 
to the House of Delegates. CAPT R. S. Howell at- 
tended as Panama Canal Zone Delegate. CAPT R. 
F. Tuck chaired the Naval Dental Reserve Officers' 
Meeting. CAPT G, H. Rovelstad served as Vice 
Chairman of the Research Section. CAPT A. W. 
Grant served as Vice-Chairman, Section on Oral 
Roentgenology. 

CAPT P. C. Alexander presented a paper titled 
Periodontal Splints. In a Public Health symposium 
on topical fluorides, RADM F. M. Kyes served as a 
panelist and presented a paper titled Navy Expe- 
rience and Viewpoint. In an Operative Dentistry Fo- 
rum on the Conservative Approach to Dental Prob- 
lems, CAPT G. W. Ferguson served as Moderator. 

Among table clinics were: Tattoo Your Patient 
with Good Dentistry by CAPT K. L. Longeway; 
Kiddies Need Foils by CDR C. A. DeLaurentis; and 
Specialists Need to do Foils by CAPT T. C. Pablos. 

Among the scientific and educational exhibits was 
Dentistry in the Armed Forces. This joint Armed 
Forces exhibit was monitored by representatives of 
each service. Naval Dental Corps monitors were 
CAPT S. E. Tande and CAPT J. B. Lepley. CAPT 
Tande served as Chairman of the Armed Forces 
Committee for production of this exhibit. 

In the ADA'S continuous motion picture program 
were five films produced in conjunction with the Na- 
val Dental Corps' training programs. Introduced and 
monitored by CAPT S. E. Tande, these films were: 
Periodontal Disease, Prevention and Early Treat- 
ment; Preventive Dentistry: Prevention of Oral Dis- 
ease; Intraoral Roentgenography: Improved Equip- 
ment and Technique; Immediate Denture Service: 
Coordinated Management; and Surgical Endodon- 
tics. Included in the closed-circuit television 
program were three video tapes produced in conjunc- 
tion with the Naval Dental Corps' training pro- 
grams. Monitored by CAPT S. E. Tande, these 
tapes were: Parts of a Removable Partial Denture 
and Their Functions by CAPT F. J. Kratochvil; Im- 
pressions and Casting Procedures for Removable 
Partial Dentures by CAPT F. J. Kratochvil; and TV 



Production Technics in Pre-clinical Dentistry by 
CAPT F. J. Kratochvil and CAPT P. F. Fedi. 

CAPT V. J. Niiranen and CAPT J. B. Lepley 
presented papers before the Annual Meeting of the 
American Academy of Maxillofacial Prosthetics, 
held 4-5 November 1965, in Las Vegas, Nevada. 
CAPT Niiranen's paper was entitled The Prosthetist 
and Audio-visual Aids. CAPT Lepley's paper was 
entitled Use of Silastic in Somato Prostheses. 

CAPT P. C. Alexander, presented a paper en- 
titled Correlations of Roentgenographic and Clinical 
Evidence of Periodontal Disease before the Ameri- 
can Academy of Oral Roentgenology, 5-11 No- 
vember 1965, in Las Vegas, Nevada. CAPT A. W. 
Grant served as Program Chairman and Moderator, 
Scientific Session, American Academy of Oral 
Roentgenology. 

DENTAL OFFICER PRESENTATIONS. RADM 
F. M. Kyes presented a paper entitled Temporo- 
mandibular Joint Disorders and Occlusion before 
the New Orleans Dental Society Conference held 
24—27 October 1965, in New Orleans, Louisiana. He 
also presented a short talk before Naval Reserve 
Dental Officers of the EIGHTH Naval District 
during a military seminar held 26 October 1965, in 
New Orleans. 

CAPT T. J. Pape DC USN, U.S. Naval Training 
Center, Great Lakes, Illinois, presented a lecture en- 
titled, Traumatic Facial Injuries before members of 
the U.S. Naval Reserve Dental Company 9-6 on 1 6 
September 1965, in Evanston, Illinois. CAPT Pape 
also presented a lecture entitled Dental Office Emer- 
gencies and another entitled Endodontia and Minor 
Oral Surgery before the 13th Annual Mississippi 
Valley Dental Meeting on 13 October 1965 in Mo- 
line, Illinois. 

LCDR J. E. Klima DC USN, of the Great Lakes 
U.S. Naval Training Center, attended the dental so- 
ciety meeting in Moline and presented a lecture en- 
titled Preventive Dentistry. 

CAPT M. A. Mazarella DC USN, U.S. Naval 
Biological Laboratory, Oakland, California, present- 
ed a paper entitled Epidemiological Studies Aboard 
a Polaris Submarine before a symposium on Recent 
Developments in Research Methods and Instrumen- 
tation on 5 October 1965 at the National Institutes 
of Health, Bethesda, Maryland. 

CAPT G. H. Rovelstad, Dental Research Facility, 
U.S. Naval Training Center, Great Lakes, Illinois 
participated in a conference entitled Role of Oral 
Cavity Research in the Study of Tobacco Used and 
Human Health sponsored by the Council for To- 



U.S. NAVY MEDICAL NEWS LETTER 



19 



bacco Research, USA on 16 October 1965 in New 
York City. CAPT Rovelstad's role is that of an in- 
vestigator involved in studies of salivary secretions 
called to the conference to consider means in which 
tobacco use may affect salivary secretions or salivary 
gland function. The benefits to be derived by the 
Navy is related to the exchange of research informa- 
tion on subjects closely allied to current studies in 
progress at Great Lakes. 

CDR J. J. Thomas Jr., DC USN presented an es- 
say entitled The Effect of Gold Condensation on the 
Human Pulp before the Annual Session of the Amer- 
ican Academy of Gold Foil Operations on 5 No- 
vember 1 965 in Los Angeles, California. CDR L. V. 
Hickey, U.S. Naval Hospital, San Diego, California, 
presented a chair-side demonstration of Application 
of Rubber Dam at the same meeting. 

CDR P. V. D. Reitz Jr., and LT S. H. Hardison, 
U.S. Naval Dental Clinic, Philadelphia, Pennsyl- 
vania presented two lectures entitled Distal Extension 
Partials, and Immediate Complete Dentures before 
the Lehigh Valley Dental Society on 17 November 
1 965 in Allentown, Pennsylvania. 

CHANGE OF COMMAND AT NDC YOKO- 
SUKA. CAPT W. C. Wohlfarth Jr. recently re- 
lieved CAPT D. E. Cooksey as Commanding 
Officer, U.S. Naval Dental Clinic, Yokosuka, Japan. 
The ceremony was attended by nearly 200 people 
which included many distinguished guests such as 
representatives of various military commands 
throughout Japan and civilian professional persons 
including the Mayor of Yokosuka, the Honorable, 
and Mrs. Masayoshi Nagano. 

CAPT Cooksey, who has been appointed SIXTH 
Naval District Dental Officer, received a letter of 
appreciation for distinguished service rendered from 
Admiral T. Nishimura, Chief of Staff, Japanese Mar- 
itime Self Defense Force. 

YOUNG NAVY DENTISTS OBSERVE SHIP- 
BOARD DRILLS. LCDR J. A. Bodner, Dental 



Officer, USS FULTON (AS-11), assisted by 
LCDR J. P. Williams and LT D. C. Eldridge, hosted 
nine dental officers of the U.S. Naval Submarine 
Base New London, Connecticut, on 8 - 9 September 
1965. In addition to the ship-board orientation 
which included an opportunity to observe and partic- 
ipate in various underway drills, Doctor Bodner de- 
livered a presentation on current advances in crown 
and bridge therapy. Those participating in the two 
day cruise were Lieutenants: G. L. Beeman, S. M. 
Blechner, J. S. Burrus, E. G. Grace, D. N. Haeger, 
L. M Hunt, T. W. Littlefield, P. C. Steadman and 
C. D. Young. 

NAVAL DENTAL CORPS OFFERS NEW 
CORRESPONDENCE COURSE. The Naval Den- 
tal Corps is offering a new correspondence course, 
Removable Partial Dentures: Planning and Design 
(NavPers 10511). The text for the course (NavPers 
1 0485) was written by CAPT A. R. Frechette DC 
USN (Ret), formerly Commanding Officer, U.S. 
Naval Dental School, NNMC, Bethesda, Maryland. 

The new course offers a brief but valuable review 
of the general principles underlying removable par- 
tial denture design and can serve as a useful starting 
point for a better understanding of partial denture 
prosthetics. The text, which is profusely illustrated, 
analyzes the forces that may damage the teeth and 
the edentulous ridges and suggests how each part of 
the denture may be designed so as to limit and dis- 
tribute these forces. 

Removable Partial Dentures: Planning and De- 
sign consists of one assignment and is evaluated at 3 
Naval Reserve promotion and/or retirement points. 
Enrollment in the course can be accomplished by 
applying on form NavPers 992 directly to the Com- 
manding Officer (Code E-43), U.S. Naval Dental 
School, National Naval Medical Center, Bethesda, 
Md. 20014. Inquiries regarding eligibility for the 
course should be sent to the same address. 



20 



U.S. NAVY MEDICAL NEWS LETTER 



OCCUPATIONAL MEDICINE SECTION 

THE WORTH OF OCCUPATIONAL HEALTH PROGRAMS 

A NEW EVALUATION OF PERIODIC PHYSICAL EXAMINATIONS 
John V. Grimaldi, Ph.D., New York, N.Y., Journal of Occupational Medicine 

7(8): 365-373, August 1965. 



In the market place, where business managers 
face the final test of their decisions, the principal — 
perhaps only — consideration is what one gets for his 
money. Unless the purchaser and vendor have a way 
of measuring values, no transaction is likely, or if a 
sale is made, it may not fully satisfy both parties. 

The fiscal merit of occupational health programs 
has been difficult to express, and this must be an 
obstacle to their acceptance. While employers are 
convinced that, without a health service their ex- 
penses would increase, they have no idea what the 
net savings may be. Moreover, they cannot quantify 
the effect of alterations in their programs' quality. 
As a consequence, one sees varying degrees of en- 
thusiasm for plant health services. Some health serv- 
ices are supported unstintingly; others operate on a 
marginal level. In any event, it is likely that neither 
the health professional nor his employer are ever 
certain that the arrangements are properly effective 
for their situation; but then, neither can say what 
should be the most practical operating conditions. 

Unfortunately there is a maximum of generaliza- 
tions and a minimum of incontrovertible specifics in 
the resource material relative to occupational health 
programs. Lacking most is the means for measuring 
the program's over-all effectiveness. Even the ap- 
praisal of its individual elements is difficult and often 
is essentially impossible. In some cases there is con- 
troversy among authorities, and the employer, who 
is left with little to guide him but his good sense, 
often must make a decision that flies in the face of 
authority. 

An important component of occupational health 
programs that suffers from contradictory opinions of 
its merit is the periodic health examination. In 1922 
the American Medical Association House of Dele- 
gates approved the idea of periodic medical exami- 
nations of "persons supposedly in health". After more 
than 40 years, the question is still unsettled as to 
whether the examinations are practical when then- 
yield is weighed against the time, cost, facilities, 



skill, and energy required to provide them. Most 
physicians can report one or more dramatic ex- 
amples where early diagnosis has prompted life-sav- 
ing cures. However, no clearcut conclusions can be 
drawn because of the absence of systematic studies. 

The controversy, and its important bearing on 
effective, practical health programs, has prompted 
considerable writing by both sides. 

REVIEW OF THE LITERATURE 

In 1922, in a study of 95,000 physical examina- 
tions of 6,000 persons, conducted between 1914 and 
1921, it was found that there were 28% fewer 
deaths among the examined individuals than would 
have occurred if the normal mortality had been 
reached. The cost of examination of the 6,000 sub- 
jects was approximately $40,000, while the mone- 
tary value of the saving of lives was estimated at 
more than $126,000. Unfortunately, there is no indi- 
cation in the report of whether this desirable result 
could be truly attributed to the physical examina- 
tion. The same study has been described at greater 
lengths but did not clear up this question. 

Two thousand two hundred examinations done 
over a 4-year period were reported on. The authors 
agreed to diagnose only those conditions that were 
producing symptoms or that had a bearing on health 
at the time or in the future. Thus, 230 separate cases 
of disease were diagnosed in 2,178 examinations. 
Some were diagnosed many times, others only once. 
Frequent significant diagnoses, in descending order, 
were obesity, osteoarthritis, hypertensive cardiovas- 
cular disease, arteriosclerotic heart disease, hyper- 
tensive vascular disease, generalized arteriosclerosis, 
anemia (hypochromic or secondary), duodenal 
ulcer, polyp of rectum and sigmoid, hypertrophy of 
prostate, hypothyroidism, and diabetes mellitus. The 
authors concluded by lamenting the lack of uniform- 
ity in reporting of examination results and believed 
that the effectiveness of periodic physical examina- 
tions could be judged more accurately if examiners 



U.S. NAVY MEDICAL NEWS LETTER 



21 



were to adopt a uniform system of recording. The 
report does little more than sharpen the curiosity of 
those who wonder what precisely the net gain may 
be from a periodic health examination. 

Five hundred executives over a period of 5 years 
were examined. On the initial examination, 52% 
were found to have one or more "defects" requiring 
treatment, and of these defects, 69.8% were not 
known to exist prior to the examination. Unfortu- 
nately, however, the significance of the "defects" was 
not defined, and the value of the discoveries is not 
clear. 

Reporting on the "investment value" of a physical 
examination program, referred to the diagnosis of 
"significant disease", which he defined as any condi- 
tion which, if not treated, would be expected to 
cause substantial medical care or hospitalization, ex- 
cessive sickness absence from work, or death or ma- 
jor impairment of physical or mental capacity prior 
to age 65. Examination results for 1455 employees 
are reported in detail. There were 533 original diag- 
noses of disease; 27% of these involved "significant 
disease". Eighty-five percent of the diagnoses were 
made in the absence of symptoms. Thirty-eight per- 
cent of the examined group had significant disease, 
and the examiners believed that 83% of these would 
benefit from future care. The "investment value" of 
the program was indicated by an example: 31 diag- 
noses (less than 3% of the total) were of early rec- 
tal growths. Prospective company savings from the 
treatment of the growths and the avoidance of 
cancer were estimated to exceed $120,000, a figure 
more than 4 times the cost of the examination pro- 
gram. However, this cheerful assumption is clouded 
by the question as to whether so large a benefit, if 
any, really derived from the examination. The fail- 
ure to make a comparison with a control group and 
to test the differences statistically leaves us with 
nothing more than another appetizing morsel, when 
something more substantial is wanted. 

A 4-year periodic health examination program 
involving 750 individuals examined annually or 
biennially was reported. Ninety-seven percent of the 
subjects were men who held executive positions. 
New "diseases" (previously not known to be pres- 
ent) were found in 35% of the cases, and 70% of 
the disorders required treatment. In only slightly 
over 30% of the newly discovered diseases were 
there any symptoms attributable to the disease. A 
critical review was made of annual physical exami- 
nations in the automobile industry. It was argued that 
their practicality is controversial and concluded that 
scheduled periodic examinations would be most ap- 



propriate for (1) those employees having the more 
hazardous occupations, (2) chronic absentees, (3) 
the aged, and (4) those requiring special examina- 
tions. 

Investigators evaluating cancer detection exami- 
nations customarily report success in the identification 
of asymptomatic cancer. A report on 2111 initial 
examinations of adults conducted by the Department 
of Public Health and Preventive Medicine of Cornell 
Medical College and the New York City Department 
of Health revealed the following: 

1. Twenty-seven (1.3%) of the subjects were 
found to have cancer, even though the group had 
been pre-screened to exclude persons with symptoms 
suggesting malignancy. 

2. More than half of the subjects found to have 
cancer were without symptoms. Subjects with 
asymptomatic cancer constituted 0.8% of all persons 
examined. 

3. Precancerous neoplasms and other lesions re- 
quiring care as a precaution against cancer were pres- 
ent in 14.3% of the subjects. 

4. Routine proctosigmoidoscopy revealed neo- 
plastic lesions in 5% of males and 3.7% of females 
on first examination. An additional 2.7% had such 
lesions on re-examination after approximately 1 year. 
The significance of these findings to the employer is 
not clear. Many factors, such as age, education, and 
the economic level of the persons in the sample, 
tend to influence the results, and the study may not 
duplicate an employment situation. 

A report on a periodic health examination pro- 
gram, involving nearly 1,000 individuals examined 
on an annual or biennial basis, indicated that 22% 
were found to have developed "significant" new dis- 
ease in the 1-to 2-year intervals since the initial 
examination. The subjects were mostly executives 
averaging 50 years of age; ninety-seven percent were 
men. Significant new disease was discovered in 1 of 
3. 

A report was made on an executive health pro- 
gram after it had been in operation for 1 year. Ma- 
jor diseases ("one that severely affects health and 
need not necessarily be related to the specific diag- 
nosis itself") were found in a little more than 25% 
of the persons examined. This compares with the 
number (1 out of 3) of significant new diseases dis- 
covered in the study reported above. Of the 307 
subjects examined, 150 were classified as "normal". 
In two reports about 5 years later it was stated that 
the program then included 648 men out of 954 who 
were eligible. It indicated that about 50% of the in- 



22 



U.S. NAVY MEDICAL NEWS LETTER 



dividuals examined had conditions of medical signifi- 
cance, major in themselves or precursors of poten- 
tially serious disease. In 16%, the presence of 
known disease was confirmed; 20% had asympto- 
matic significant disease, and 13% had significant 
disease which was symptomatic at the time of exam- 
ination, The 5-year follow-up revealed that 17% 
of the persons were cured of the conditions discov- 
ered by the examinations, 12% were worse, 6% 
were dead, 35% unchanged, and 31% improved. 

With respect to malignancies, it was concluded 
that "the less than 1% found in cancer detection 
clinics would not warrant the time and cost involved 
in large-scale routine x-ray surveys". The eight ma- 
lignant tumors detected in the course of the periodic 
examinations in this series were nearly all associated 
with definite symptoms. In a further 10-year follow- 
up of 717 persons, mostly men aged 40-65 years 
(70% of those eligible), 59% (421) had conditions 
of major medical significance or precursors of poten- 
tially serious disease. Of these, approximately 10% 
had symptoms which were of concern to them, but a 
sizable number, 36% were entirely asymptomatic. 
These investigations, which collectively studied the 
issue in greater depth than most, regrettably do not 
relate the findings to the oft-mentioned criticism that 
the cost of periodic health examination programs ex- 
ceeds the value. 

An appraisal of 1,500 examinations selected at 
random from 4,224 periodic examinations in the ho- 
tel industry also does not relate the results to the 
costs of conducting the program. 

One report concludes that critical scrutiny of the 
health examination shows it to be practical only for 
selected groups and individuals, especially those who 
want the examination and will profit by it. Two 
hundred subjects were segregated into two groups: 
those who had never had a health examination be- 
fore ("newcomers") and those who had a health ex- 
amination within the past 4 years ("repeaters"). 
The examinees in both groups were rated with re- 
spect to the presence or absence of 20 physical de- 
fects. Statistical evaluation showed practically no 
significant difference between the 2 groups. It was 
reported that, with respect to fatal diseases, how- 
ever, almost 4 out of 5 deaths occurring in the 
United States in 1948 were attributed to a chronic 
disease and, of these, about Va were caused by a 
disease which could be considered detectable. To 
what degree the diseases would be amenable to 
treatment at the time of discovery is moot. 

The report describing the results of examinations 
of 583 persons (296 men and 287 women), again 



demonstrates that health examinations can result in 
identification of important diagnostic entities. The 
sample consisted of "supposedly healthy" people 
over the age of 45. Cancer was present in 1 out of 
146, and other significant tumors were found in 1 
out of 18. Significant heart disease not previously 
recognized was present in 1 of 25. When known 
heart disease was included, nearly 1 in 10 had some 
form of heart disease. Previously undiagnosed duod- 
enal ulcers were found in 1 in 58 cases (duodenal 
ulcers totaled 1 in 20 including known cases). Cases 
of previously undiagnosed diabetes numbered 1 in 
48 (1 in 32 among the known). This study, how- 
ever, like others does not provide a clear insight 
into the relative value, to an employer, of such a 
program, nor does a study of 391 employees exam- 
ined over a 19-month span and in which 713 ab- 
normalities were diagnosed (534 not detected pre- 
viously) and 17 employees had conditions definitely 
considered to be precancerous. 

In a critical review of the evidence for and against 
periodic health examinations covering 45 years, it 
was observed that physicians have found that from 
15 to 45% of supposedly well individuals examined 
(most of them adult males) had significant diseases 
or defects of which they were unaware. The report 
concluded that, even in the best hands, periodic 
health evaluations may fail to detect life-threatening 
disease. 

In a study of the value of multiphasic screening to 
determine whether the physical examination re- 
vealed disease that was missed by the history or clin- 
ical tests, 753 persons were screened. Three hundred 
ten of these were referred for conditions previously 
unknown or not under treatment by the family phy- 
sician; 439 previously unknown or untreated defects 
associated with major disease were found. Again, 
however, the relative value of the discoveries with 
respect to an industrial health program remains for 
conjecture. 

In another study, defects of function or structure 
were detected in about 60% of executives exam- 
ined; about 40% of the subjects were unaware of 
the abnormal conditions. 

In the first year of a faculty periodic health exam- 
ination program, 294 examinations were complet- 
ed (263 men and 31 women). Eighty-one percent 
were found to have a total of 465 "significant" de- 
fects of which they were previously unaware. In a 
follow-up study of the second year's results, 269 
people were examined (241 men and 28 women). 
Seventy-five percent were found to have previously 
unknown significant defects. 



U.S. NAVY MEDICAL NEWS LETTER 



23 



One study involved 765 male executives during a 
7-year periodic physical examination program. Of 
these subjects, 199 were temporarily disabled 8 or 
more consecutive days for causes other than upper 
respiratory infection or gastrointestinal disturbances 
on one or more occasions. The disease which pro- 
duced disability was diagnosed at the periodic exam- 
ination prior to the disability in 37.1% of the 
cases; 33.6% of the disabilities were not diagnosed 
by the examining physician. These were almost entire- 
ly acute diseases which did not exist and could not 
have been anticipated at the time of the examina- 
tion. The study concludes that the contention that 
"life-threatening" disease usually is discovered be- 
tween examinations is not true. However, there was 
not conclusive evidence that the course of any em- 
ployee's disease was changed by virtue of the early 
diagnosis. 

An important consideration, when assessing the 
merits of periodic health examinations, is the extent 
to which recommendations are followed. None of 
the reported analyses of health examinations eval- 
uated this effect. Five hundred and seventy-four 
male executives were studied to determine their de- 
gree of compliance with recommendations received 
at executive health examinations. Recommendations 
were made to 435 individuals and follow-up infor- 
mation was obtained on 382. It was found that fol- 
lowing a single examination, 23% of the subjects 
failed to comply, 10% partially complied, and 67% 
totally complied with the recommendations. Com- 
pliance was obtained in only 72% of the total rec- 
ommendations made. Various factors affecting 
compliance were studied. It was found that although 
the amount of disease detected and the severity of 
the disease increased with increasing age, com- 
pliance with recommendations decreased. A signifi- 
cant difference was found between compliance with 
recommendations for previously diagnosed and for 
newly detected disease entities. No significant differ- 
ence could be detected between compliance with 
recommendations for more significant and for less sig- 
nificant disease, for diagnostic as opposed to thera- 
peutic recommendations, or for medical as opposed 
to surgical recommendations. The problem of partial 
compliance was studied, and it was found that, as 
the incidence of recommendations per individual in- 
creased, compliance increased. Variation in com- 
pliance with recommendations, when categorized by 
topographical systems, was found to occur, com- 
pliance being obtained in only 57% of recommenda- 
tions involving the cardiovascular system. The 
effects of repetitive examinations were studied in 



141 of the examinees, of whom 109 had 2 and 32 
had 3 examinations. It was found that compliance 
improved significantly and progressively with suc- 
ceeding examinations. 

In a critique of the physical examination program 
in industry it was observed that, when carefully and 
selectively applied, the program has only a restricted 
role in the majority of industrial operations. The 
report goes on to say that the examination is of com- 
paratively little value in defense of industrial insur- 
ance claims; its value of health insurance can be 
questioned on the record. 

PRESENT STUDY 

From a review of the literature it appears clear 
that the examination of hypothetically healthy indi- 
viduals frequently reveals physical defects which of- 
ten were unsuspected. The significance of the find- 
ings, with respect to the cost of their identification 
and the value of their contribution to furthering the 
individual's health, is unclear however. 

To an extent which may be greater than is real- 
ized, the undefined worth of periodic physical ex- 
aminations affects the image of the occupational 
health program and its possibility of achievement. 
Industrial physicians who do not include the exam- 
inations in their programs, imply it is not an im- 
portant feature, and the omission is treated lightly 
since its effect is difficult to appraise. On the other 
hand, proponents of the examinations may appear 
somewhat impractical to an unsympathetic observer, 
since the examination's value is not incontrovertibly 
manifest. 

The reservations of cost-conscious physicians and 
employers generally have relegated the periodic 
health examination to a special place in occupational 
health programs where often it is used only in rela- 
tively uncommon situations. Thus, employees in cer- 
tain hazardous occupations and executives usually 
constitute the population the examinations serve. 
Whether this is a justifiable limit to impose on peri- 
odic health examinations is a perplexing question. It 
would seem they should be extended to a wider 
circle of employees if the implications for greater 
health and safety are valid. This implicit promise 
also suggests possibilities for reducing the expense of 
employee illness, which both the employer and the 
employee bear, in several possible ways. The fact 
that the examinations are not more widely employed 
contradicts the logical reason for their existence. 

This anomalous situation apparently has been 
difficult to resolve and doubtless is due to an inabil- 
ity to satisfy critics who assume a pragmatic atti- 



24 



U.S. NAVY MEDICAL NEWS LETTER 



tude. However, if the examinations are as effective 
as their protagonists hold, one should be able to de- 
scribe their worth in dimensions that can be appre- 
ciated by any critic. In fact, it is necessary to do so 
since, in the business setting, competition makes it 
imperative to be able to show clearly how an activity 
contributes to the aims of the enterprise; otherwise it 
is controverted and its existence jeopardized with 
consequent reflections on its sponsors. 

The absence of easily read dimensions and the 
challenge this deficiency presents seem clearly implic- 
it in the literature review. In an attempt to overcome 
the inadequacy, a statistical study was undertaken 
which compared the medical and surgical ex- 
penses submitted by employees participating in the 
General Electric Insurance Plan. The study tested 
the assumption that individuals who receive an ap- 
propriate physical examination periodically will be 
better able to maintain a healthy state than those 
who are not examined. The difference between the 
examined and unexamined with respect to the hospi- 
talization, doctor fees, and related expenses incurred 
from year to year was assumed to be an indication 
of differences in the health status of the population 
studied. Experimental and control samples were es- 
tablished with relatively good matching of possible 
extraneous influences. 

Periodic physicals have been offered for many 
years to middle-management employees (i.e., 
members of the Elfun Society) at the General Elec- 
tric Company's manufacturing locations in Schenec- 
tady. Some have taken advantage of the opportu- 
nity; others have not. Thus, there exists in Schenec- 
tady a sizable "experimental" group of periodically 
examined Elfuns and a "control" group of nonpartic- 
ipants. An Elfun periodic health examination pro- 
gram has never been undertaken at the Fort Wayne 
plants of the Company. Therefore, a second control 
group was available, composed of employees with an 
economic, social, and education level equivalent to 
Schenectady's and drawn from a community having 
similar socioeconomic values. 

PROCEDURE 

The Schenectady preventive health examination 
was evaluated first. It consists of the following: 

1. A thorough, self-administered, health-inven- 
tory questionnaire. 

2. Physical examination (subject completely dis- 
robed). 

3. A 14 X 17 x-ray film of the chest. 

4. Audiometric testing. 



5. Visual acuity testing. 

6. Tonometry for those age 40 and above. 

7. A 12-lead electrocardiogram. 

8. Urinalysis for albumin and sugar, and micro- 
scopic survey of spun-down sediment. 

9. Hematocrit and microscopic study of the blood 
smear. 

10. Fixed-end-point blood sugar determination 
(Wilkerson-Heftman Method) . 

1 1 . Proctoscopic examination when indicated 
(i.e., not routine). 

The company's Medical Advisory Council ap- 
praised these examination units as a "jury of ex- 
perts" and agreed that the examination would detect 
diagnostic entities which when corrected would in- 
crease the examinees' longevity and decrease high 
medical expense. 

The sampling procedure for the Schenectady 
group provided a random number of the Elfuns 
there. One of every 10, drawn from an alphabetical 
list, was included. Thus the Schenectady sample 
consisted of 74 Elfun examinees and 26 nonexamin- 
ees. For Fort Wayne, all the Elfuns — 94 members — 
were included. 

The covered medical expenses for the years 1956 
through 1963, incurred by each of the employees in 
the study was obtained from the insurance carrier. 

Divers statistical analyses were made, comparing 
the medical expenses of the Schenectady periodic 
examinees with those of the nonexaminees and the 
Fort Wayne Elfuns. The statistical significance of 
the differences between the averages for each com- 
parison were subjected to the test to determine 
whether they were truly significant and not merely 
due to coincidental fluctuations in the data. 

FINDINGS 

The average expense for the unexamined is sig- 
nificantly higher than the average for the examined. 
Comparisons between the examined sample and 
both unexamined groups indicates the average medi- 
cal insurance claim is substantially higher for the un- 
examined, with good statistical significance. (The 
Fort Wayne expenses were adjusted 3% upward. 
This is believed to be a conservative increment to 
bring the charges more in line with higher Schenec- 
tady costs, according to data provided by the Metro- 
politan Life Insurance Company.) 

As the employee permits time to elapse between 
his examinations, the average expense appears to in- 
crease and approaches the average expense claim for 



U.S. NAVY MEDICAL NEWS LETTER 



25 



the unexamined. There appears to be strong reason, 
statistically, to believe that the favorable claim dif- 
ference for the examined group — in this comparison 
— is due to factors that are distinctive and not due 
to chance. 

For the period 1956-1963 it was found that exam- 
inees averaged a somewhat higher ratio of claims 
per person than did the nonparticipants. It might be 
assumed that this is due to the prompting of examin- 
ees to obtain medical care following their examina- 
tion. However, the assumption seems to be refuted 
by the observation that the fewest claims per person 
are filed in the year of examination. The number of 
claims per examinee tends to increase as the years 
elapsed between examinations increases and the av- 
erage for the 8 -year span therefore is raised. This 
conforms with the finding noted above that, on the 
average, the expense per claim increases with the 
time lapse between examinations. 

Occasions for payment for the treatment of cor- 
onary heart disease, circulatory disorders, malig- 
nancies, and diabetes in the unexamined sample 
were somewhat higher than for the examined. The 
total number of entities per examinee indicated a 
slightly greater number of occasions for incurring 
medical expense than for the unexamined, but the 
lower average expense claim for the examined would 
seem to de-emphasize the possibility that the compar- 
atively greater number of diagnostic entities por- 
tends a likelihood of greater expense. 

DISCUSSION 

Although many writers have described the efficacy 
of periodic health examinations, a literature review 
revealed no evidence that any have measured mone- 
tarily the examination's worth. Some have spoken of 
an inherent investment value, but the relationship 
between the cost of periodic examinations and their 
possible effect on the individual's medical expenses, 
as a function of the examination's effect on health 
maintenance, appeared unexplored. The issue has 
significance since some writers challenge the merit of 
periodic physical examinations on such practical 
grounds. 

In order to gain some insight into this cost-result 
relationship, a comparative analysis was made of ex- 
amined and unexamined employees' medical ex- 
penses, over an 8 -year span. Differences between an 
experimental (examined) group and two control 
(unexamined) groups were statistically tested. The 
comparisons indicated that: 

1 . The number of medical insurance claims per 



examined claimant increases with the time between 
examinations. 

2. The smallest number of claims occurs during 
the year of examination. 

3. The difference between the examined and un- 
examined, with respect to the average number of 
claims per claimant, is negligibly small. 

4. The medical expense per claimant increases as 
the time between examinations increases. 

5. The average claim is greater for the unexam- 
ined, and the difference tends to exceed signifi- 
cantly the cost per periodic health examinations. 

With relatively good statistical probability it is 
possible to say that the periodic physical examina- 
tion has demonstrable values for the occupational 
health program and its employer. The return on in- 
vestment would seem to be significant when the cost 
per examination (at our medical centers this ap- 
proximates $30) is compared with the difference 
between the medical expense claims for the exam- 
ined as opposed to the unexamined. In the case of 
a biennial examination the difference is about $200 
per claim. 

It appears, therefore, that the periodic health exam- 
ination should be considered a substantive com- 
ponent of the effective occupational health program 
and that its individual contributions can be direct 
and substantial. The examination's implied assist- 
ance in disease control, noted in the significantly 
smaller sickness expense claims for the examined, 
may be expected to lower insurance costs for both 
the employer and his employees. Reduced sickness 
absenteeism rates and maximized employee effective- 
ness may also be expected to follow. 

The study could not delimit practically the effect 
of differences in personal health motivation. Exam- 
inees participated in the examination program vol- 
untarily, and it may be assumed that they possessed 
a more earnest attitude toward health maintenance, 
with consequent beneficial effects. A further suppo- 
sition is that the health appraisal completed at the 
employer's medical center as opposed to the examin- 
ation that is not work-oriented, is more searching 
with respect to the identification and treatment of 
subclinical, but obviously wholesome stresses, hab- 
its, or practices which may inhibit work and the 
effectiveness of the employee. It is possible that at- 
tention to these factors assists the profit objectives of 
the business as much or more than the advantages 
observed in the medical insurance costs for the exam- 
ined employees. 

The evidence that claim costs are lower for the 



26 



U.S. NAVY MEDICAL NEWS LETTER 



regularly examined, particularly the biennially exam- 
ined, tends to support findings reported that com- 
pliance with recommendations improved signifi- 
cantly and progressively with the subsequent exam- 
inations. The personalized opportunity, at the 
close of the periodic examination, when the doctor 
communicates his observations, may be expected to 
have an important influence in this respect. 

The values implicit in the Schenectady periodic 
health examination probably are greater than the 
data imply. Many of the employees in the unexam- 
ined samples undoubtedly obtained periodic physi- 
cal examinations from time to time at outside diag- 



nostic centers. Their experience might be expected 
to have modified the data to favor the unexamined 
groups. The significant medical expense differences 
for the examined, therefore may be more remark- 
able. 

This study will be followed by another to validate 
the findings, but its implications are clear that occu- 
pational health programs assist the profit objectives 
of the business in ways that can be measured and 
the important periodic health examination compo- 
nent of the program may provide direct savings which 
exceed any expected. 



EDITORIAL DESK 



AVAILABILITY OF PSYCHIATRIC 
RESIDENCIES IN NAVAL HOSPITALS 

The Neuropsychiatric Branch announces the avail- 
ability of a limited number of vacancies in the ap- 
proved Navy psychiatric residency training program. 
Each year there are only twelve openings for Navy 
psychiatric residents beginning at the first year level. 
The Navy hospitals which have residency training 
programs in psychiatry are Bethesda, Maryland; 
Oakland, California; and Philadelphia, Pennsylva- 
nia. Currently, Bethesda, and Oakland are fully ap- 
proved for the required three years' training. Phila- 
delphia is approved for two years' training (the third 
year being given at Bethesda) ; plans are underway 
for obtaining approval for third-year training at 
Philadelphia to bring the program there up to full 
accreditation. 

Prospective residents often ask whether any Naval 
hospital can offer completely satisfactory residency 
training utilizing its own facilities and at the same 
time meet the requirements of the review committees 
of the various national approving and accrediting 
bodies. The same question could be asked of any 
hospital, civilian or military. The Navy's psychiatric 
residency training program, as necessary, affiliates 
with local civilian psychiatric facilities in rounding 
out certain aspects of the training program. Affilia- 
tion with state psychiatric hospitals affords extensive 
experience with chronic hospitalized psychotic pa- 
tients. Full time assignments may also be made in 
one or more of the three programs for the purpose 
of acquiring experience in neurology, in psychiatric 
outpatient clinics and in child guidance clinics. Civil- 
ian consultants also participate extensively in the 



program by conducting regular seminars and super- 
vising long term therapy cases. The training expe- 
rience in Navy hospitals includes inpatient and outpa- 
tient psychiatry ranging through the entire diagnostic 
spectrum. Types of therapy taught and utilized in- 
clude all that are available, i.e., individual and group 
psychotherapy, chemotherapy, somatic therapy, oc- 
cupational, and milieu therapies. Both male and fe- 
male patients of all ages are seen for evaluation and 
treatment as indicated. Each training hospital is lo- 
cated in a metropolitan area where there are avail- 
able academic lectures, short courses, and medical 
schools with excellent psychiatric departments. The 
psychiatric training program is further enhanced by 
relevant research programs of considerable variety. 
Thus, it can be seen, the resident is exposed to and 
guided through an extensive range of clinical and 
academic psychiatry. 

Upon completion of residency training, psychia- 
trists have available a wide variety of assignments 
offering diverse opportunities and challenges, rang- 
ing from assignment to the staff of neuropsychiatric 
training hospitals to duty as psychiatrist with a Ma- 
rine Division. Each of the assignments includes 
ongoing professional experience as well as increasing 
responsibilities commensurate with the individual's 
training, experience and motivation. Tours of duty 
are relatively stable, depending upon the individual 
situation and needs of the service. The career Navy 
psychiatrist can expect to progress to Board certifi- 
cation, again depending upon his own motivation, 
and to increasingly responsible assignments up to 
Chief of the Neuropsychiatric Service of a residency 
training hospital. 



U.S. NAVY MEDICAL NEWS LETTER 



27 



The Surgeon General's Consultant Panel in Neu- 
ropsychiatry includes the following members who 
are prominent in their fields. Members of the Panel 
provide ready sources of assistance and guidance in 
dealing with all aspects of Navy neuropsychiatry. 

Francis J. Braceland, M.D. 

Editor 

The American Journal of Psychiatry 

1700 18th Street, N.W. 

Washington, D.C. 20009 

Howard P. Rome, M.D. 
Head, Psychiatry Section 
Mayo Clinic 
Rochester, Minnesota 

(and President of the American 

Psychiatric Association ) 

Cecil L. Wittson, M.D. 
Dean, College of Medicine and 
Chairman, Department of Neurology 

and Psychiatry 
University of Nebraska 
College of Medicine 
602 South 44 Avenue 
Omaha, Nebraska 

Augustus S. Rose, M.D. 

Professor of Medicine 

Division of Neurology 

School of Medicine 

The Center for the Health Sciences 

Los Angeles, California 90024 

Ewald W. Busse, M.D. 
Chairman, Department of Psychiatry 
Duke University Medical Center 
Durham, North Carolina 

Applications are reviewed by the Surgeon Gener- 
al's Advisory Board which selects residents for train- 
ing. Although most residencies start in July of each 
year, for some years residents have been started in 
psychiatry at other times of the year varying with 
vacancies available at individual hospitals which re- 
sult from completion of residency training by other 
individuals. Inquiry for further details can be made 
directly to this office. We invite those interested to 
write to: 

Neuropsychiatry Branch (Code 313) 
Bureau of Medicine and Surgery 
Navy Department 
Washington, D.C. 20390 



SECNAVNOTE 1650— CASH AWARDS 
FOR MILITARY PERSONNEL 

1. The President has signed public law 89-198. 
This law authorizes cash awards of up to $25,000 to 
military personnel for suggestions, inventions, or 
scientific achievements which contribute to the effi- 
ciency and economy of government operations. 

2. All military personnel will be informed that 
the law has been passed and that worthy contribu- 
tions — suggestions, inventions, scientific achieve- 
ments — submitted now are eligible for award consid- 
eration. 

3. The suggestion form NAVEXOS 12450/8 
(REV. 3-64) used by civilian personnel may be 
used for submitting contributions by military person- 
nel. Where these forms are not available, such as 
aboard ship or at activities not employing civilian 
personnel, contributions will be submitted in writing 
to the commanding officer, identifying the suggester 
by name, rank, and serial number. 

4. Instructions concerning the processing of 
contributions and appropriate award scales will be 
issued as soon as developed by the Navy and Marine 
Corps. 

DIRECTOR, NAVY NURSE CORPS VISITS 

NAVAL SCHOOLS COMMAND, NEWPORT, 

R.I. 

CAPT Ruth A. Erickson, NC USN visited the 
Naval Schools Command, Newport, Rhode Island 
on Friday, 8 October 1965, to participate in the grad- 
uation exercises of Class 602-N. 

Seventy-four Nurse Corps officers and one Medical 
Service Corps officer comprised the graduating class. 

During the morning activities CAPT Erickson 
officiated as reviewing officer while all companies of 
the Naval Women Officer School passed in review. 
At the afternoon graduation ceremony the Director 
of the Navy Nurse Corps was guest speaker for the 
occasion. CAPT Erickson discussed the implications 
of the 3 R triad of commissioned rank (Respect, 
Responsibility and Reward) for the newly appointed 
officers. Following her address, she administered the 
oath of office to 59 former Navy Nurse Corps Can- 
didates and presented certificates to all members of 
the graduating class. — Nursing Division, BuMed. 

NAVY MERITORIOUS CIVILIAN 
SERVICE AWARD 

Mrs. Mullie F. Jack, technical publications editor 
in the clinical research facility at Oakland Naval 



28 



U.S. NAVY MEDICAL NEWS LETTER 



Hospital for the past 18 years, has received the 
Navy Meritorious Civilian Service Award "in recog- 
nition of her many noteworthy contributions, which 
have been of high value and benefit to the Navy." It 
is the first time an employee at the hospital has re- 
ceived the award—a gold pin and a handsome cer- 
tificate, with a letter from the Navy Surgeon Gener- 
al. 

The award was presented to Mrs. Jack by RADM 
Harold J. Cokely, hospital commanding officer, be- 
fore a large group of fellow-workers and friends. It 
came simultaneously with her retirement September 
30 at the age of 70. 

In presenting the award RADM Cokely noted 
that Mrs. Jack has prepared papers for submission 
to 96 different scientific journals and distributed 
6,000 reprints requested by doctors in all parts of 
the United States and 59 foreign countries, thus 
greatly enhancing the hospital's professional reputa- 
tion. 

Prior to her employment at Oak Knoll Mrs. Jack 
held government jobs with the War Industries Board 
in Washington, D.C., and with the Army and Ma- 
rine Corps in San Diego. For six years she was sten- 
ographer and interpreter for the Division of Fruitfly 
investigation in Mexico City, Mexico. She also did 
volunteer work for the British Office of Information, 



Mexico City. — Public Information Office, U.S. Na- 
val Hospital, Oakland, California 94627. 

A MOMENT OF HAPPINESS 




Corporal John A. Heffelfinger, USMC, consoles 
"Debbie" by telling her a story. The four-year-old 
Vietnamese girl was "adopted" by Navy Corpsman 
Robert P. Dionne after he treated her infected eye. 
Dionne was later killed in line of duty, but Debbie, 
who wears the dog tag he gave her, still comes to the 
medical aid station to find her American Friend. — 
Armed Forces Press File, Week of August 29, 1965. 



U.S. NAVY MEDICAL NEWS LETTER 



29 



DEPARTMENT OF THE NAVY 

U. S. NAVAL MEDICAL SCHOOL 

NATIONAL NAVAL MEDICAL CENTER 

BETHESDA, MARYLAND 20014 



POSTAGE AND FEES PAID 
NAVY DEPARTMENT 



OFFICIAL BUSINESS 



PERMIT NO. 1048 



U.S. NAVY MEDICAL NEWS LETTER